Aphakic and phakic retinal detachment. I. Preoperative findings

Pars Plana Vitrectomy With External Drainage for Nonexudative Retinal Detachment

PURPOSE

To describe a surgical technique for retinal detachment with undetected retinal breaks, which combines pars plana vitrectomy and external subretinal fluid (SRF) drainage.

METHODS

In this retrospective observational study, patients with a diagnosis of retinal detachment with undetected retinal breaks were enrolled. Standard three-port 25-gauge (G) core and peripheral pars plana vitrectomy was performed. Perfluorocarbon liquid was injected into the vitreous cavity to obtain posterior retinal flattening. Trans-scleral 27-G needle external drainage was performed approximately at 8 mm from limbus to drain SRF subconjunctivally. Prophylactic peripheral endolaser was performed on 360°. Sulfur hexafluoride 20% was used as tamponade.

RESULTS

In 14 of 15 patients, complete SRF drainage was obtained. In only one case, SRF did not leak out in the subconjunctival space. Neither intraoperative nor postsurgical complications were recorded. Flat retina with no SRF was observed in all samples, and no retinal detachment relapses were reported at each follow-up.

CONCLUSION

External drainage combined with pars plana vitrectomy may represent a valid and safe option to drain SRF in retinal detachment cases with undetected retinal breaks. The advantages of the technique include the absence of dispersion of retinal pigment epithelium cells in the vitreous chamber, prompt dry retina, and low risk of postoperative retinal folds.

Anatomic and functional prognosis of vitreoretinal surgery in rhegmatogenous retinal detachment associated with intraocular inflammation

BACKGROUND/OBJECTIVES

The predictive factors of surgical results in uveitic retinal detachment (RD) are lacking. The objective was to study the surgical outcomes and determine the risk factors for surgical failure in rhegmatogenous RD associated with intraocular inflammation (RRDIOI).

METHODS

Retrospective series of consecutive eyes with RRDIOI undergoing vitreoretinal surgery between 2012 and 2019 in two French referral centres. Patients underwent 23- or 25 G pars plana vitrectomy (PPV), scleral buckling (SB), or a combination of both. The main objective was to describe the predictive factors of visual recovery and anatomical success after surgery.

RESULTS

Seventy-one eyes were included. Posterior and panuveitis accounted for 91.5% of eyes. Seventy-five percent of eyes had an infectious cause for their uveitis. The first surgery consisted in PPV alone, SB alone, or both in 87.3%, 4.2% and 8.5% of cases respectively. The reattachment rate was 74.6% after one surgery (100% in case of SB, either alone or in association with PPV). On multivariate analysis, the only predictive factor of visual improvement was a baseline BCVA ≥ 20/400, while the only predictive factor for surgical success at 12 months was the absence of RD recurrence within the first 6 weeks of surgery.

CONCLUSIONS

RRDIOI has a relatively favourable anatomical prognosis. The addition of scleral buckling may be beneficial in selected cases.

Bilateral sequential and simultaneous rhegmatogenous retinal detachments: anatomic and functional outcomes

OBJECTIVE

To assess the anatomic and functional outcomes in sequential and simultaneous bilateral rhegmatogenous retinal detachment (BRRD) repair.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 218 eyes in 109 patients.

METHODS

Patients diagnosed with BRRD between 2014 and 2020 at the University Centre of Ophthalmology-CHU de Québec-Laval University were reviewed. Main outcomes were single-surgery anatomic success (SSAS) and final pinhole visual acuity (PHVA) in logMARs.

RESULTS

Of the 109 patients, 86 (79%) were male, and median (Q1, Q3) age at presentation for the first eye was 60 years (range, 54-66 years). Of these patients, 92% (n = 100) had sequential BRRD and 8% (n = 9) simultaneous BRRD. Median (Q1, Q3) duration of symptoms was shorter for second eyes (first, 7 days [range, 3-15 days] vs second, 4 days [range, 2-10 days]; p = 0.028). Second eyes also had less retinal tears (first, 2.94 ± 2.76 tears vs second, 2.38 ± 1.79 tears; p = 0.031) and better median preoperative PHVA (first, 0.46 logMAR [range, 0.14-2.30 logMAR] vs second, 0.24 logMAR [range, 0.06-0.95 logMAR]; p = 0.012). SSAS was achieved in 100 (92%) and 101 (93%) of first and second eyes, respectively (p = 1.00). Final PHVA was better for the first eye (first, 0.14 logMAR [range, 0.04-0.30 logMAR] vs second, 0.20 logMAR [range, 0.04-0.43 logMAR]; p = 0.010) but comparable at 3 months (first, 0.30 logMAR [range, 0.14-0.48 logMAR] vs second, 0.34 logMAR [range, 0.13-0.70 logMAR]; p = 0.36).

CONCLUSIONS

SSAS was similar for both eyes. The subsequent eye was more likely to be treated earlier with less advanced presentations, but at 3 months, PHVA was not significantly different between eyes. Difference in final PHVA may be attributable to longer follow-up in first eyes.

Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments

BACKGROUND

A macula-involving rhegmatogenous retinal detachment (RRD) is one of the most common ophthalmic surgical emergencies and causes significant visual morbidity. Pars plana vitrectomy (PPV) with gas tamponade is often performed to repair primary macula-involving RRDs with a high rate of anatomical retinal reattachment. It has been advocated by some ophthalmologists that face-down positioning after PPV and gas tamponade helps reduce postoperative retinal displacement. Retinal displacement can cause metamorphopsia and binocular diplopia.

OBJECTIVES

The primary objective of this review is to determine whether face-down positioning reduces the risk of retinal displacement following PPV and gas tamponade for primary macula-involving RRDs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (which contains the Cochrane Eyes and Vision Trials Register) (2022, Issue 11), MEDLINE (January 1946 to 28 November 2022), Embase.com (January 1947 to 28 November 2022), PubMed (1948 to 28 November 2022), Latin American and Caribbean Health Sciences Literature database (1982 to 28 November 2022), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 28 November 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which face-down positioning was compared with no positioning or another form of positioning following PPV and gas tamponade for primary macula-involving RRDs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and assessed the certainty of the body of evidence for the prespecified outcomes using the GRADE approach.

MAIN RESULTS

We identified three RCTs (369 eyes of 368 participants) that met the eligibility criteria. Two RCTs provided data on postoperative retinal displacement, one reported on postoperative distortion and quality of life outcomes, two on postoperative best-corrected visual acuity (BCVA) in logMAR, and two on postoperative ocular adverse events such as outer retinal folds. Study characteristics and risk of bias All the trials involved predominantly male participants (range: 68% to 72%). Only one trial provided race and ethnicity information, was registered on a trial registry, and reported funding sources. Using the RoB 2 tool, we assessed the risk of bias for proportion of eyes with retinal displacement, mean change in visual acuity, objective distortion scores, quality of life assessments, and ocular adverse events, with most domains judged to be at low risk of bias. Findings Immediate face-down positioning may result in a lower proportion of participants with postoperative retinal displacement compared with support-the-break positioning at six months (risk ratio [RR] 0.73, 95% confidence interval [CI] 0.54 to 0.99; 1 RCT; 239 eyes of 239 participants; very low certainty evidence). One study found no evidence of a difference in BCVA at three months when comparing postoperative face-up with face-down positioning with or without perfluorocarbon liquid (mean difference [MD] -0.03, 95% CI -0.09 to 0.02; I2 = 0; 56 eyes of 56 participants; very low certainty evidence). Immediate face-down positioning appears to have little to no effect on postoperative distortion scores at week 26 (MD 1.80, 95% CI -1.92 to 5.52; 1 RCT; 219 eyes of 219 participants; very low certainty evidence) and postoperative quality of life assessment scores at week 26 (MD -1.80, 95% CI -5.52 to 1.92; 1 RCT; 217 eyes of 217 participants; very low certainty evidence). Adverse events One study that enrolled 262 participants with macula-involving RRDs suggested that immediate face-down positioning after PPV and gas tamponade may reduce the ocular adverse event of postoperative outer retinal folds at six months (RR 0.39, 95% CI 0.17 to 0.90; 1 RCT; 262 eyes of 262 participants; very low certainty evidence) and binocular diplopia (RR 0.20, 95% CI 0.04 to 0.90; 1 RCT; 262 eyes of 262 participants; very low certainty evidence) compared with support-the-break positioning. Immediate face-down positioning may increase the ocular adverse event of elevated intraocular pressure compared with support-the-break positioning (RR 1.74, 95% CI 1.11 to 2.73; 1 RCT; 262 eyes of 262 participants; very low certainty evidence). Another study found no evidence of a difference in postoperative outer retinal folds when comparing face-down versus face-up positioning at one and three months (RR 1.00, 95% CI 0.50 to 2.02; RR 1.00, 95% CI 0.28 to 3.61; 1 RCT; 56 eyes of 56 participants; very low certainty evidence). No studies reported non-ocular adverse events.

AUTHORS' CONCLUSIONS

Very low certainty evidence suggests that immediate face-down positioning after PPV and gas tamponade may result in a reduction in postoperative retinal displacement, outer retinal folds, and binocular diplopia, but may increase the chance of postoperative raised intraocular pressure compared with support-the-break positioning at six months. We identified two ongoing trials that compare face-down positioning with face-up positioning following PPV and gas tamponade in participants with primary macula-involving RRDs, whose results may provide relevant evidence for our stated objectives. Future trials should be rigorously designed, and investigators should analyze outcome data appropriately and report adequate information to provide evidence of high certainty. Quality of life and patient preferences should be examined in addition to clinical and adverse event outcomes.

Challenges in posterior uveitis-tips and tricks for the retina specialist

PURPOSE

Posterior uveitis is a common chorioretinal pathology affecting all ages worldwide and is a frequent reason for referral to the retina clinic. The spectrum of etiologies for uveitis is very broad and includes infectious and auto-immune diseases. Inflammation can be confined to the eye or may be a part of systemic disease. A useful outline is therefore proposed to aid in the correct diagnosis of these challenging entities. The situation is further complicated by the fact that many neoplastic conditions resemble features of posterior uveitis; they are known as "masqueraders of uveitis". Here, we summarize different posterior uveitides that present with rare findings, along with masqueraders that can be difficult to distinguish. These conditions pose a diagnostic dilemma resulting in delay in treatment because of diagnostic uncertainty.

METHODS

An extensive literature search was performed on the MEDLINE/PUBMED, EBSCO and Cochrane CENTRAL databases from January 1985 to January 2022 for original studies and reviews of predetermined diagnoses that include posterior uveitic entities, panuveitis and masquerade syndromes.

RESULTS

We described conditions that can present as mimickers of posterior uveitis (i.e., immune check-points inhibitors and Vogt-Koyanagi-Harada-like uveitis; leukemia and lymphoma associated posterior uveitis), inflammatory conditions that present as mimickers of retinal diseases (i.e., Purtscher-like retinopathy as a presentation of systemic lupus erythematosus; central serous chorioretinopathy masquerading inflammatory exudative retinal detachment), and uveitic conditions with rare and diagnostically challenging etiologies (i.e., paradoxical inflammatory effects of anti-TNF-α; post vaccination uveitis; ocular inflammation after intravitreal injection of antiangiogenic drugs).

CONCLUSION

This review of unique posterior uveitis cases highlights the overlapping features of posterior uveitis (paradoxical inflammatory effects of anti -TNF α and uveitis; Purtscher-like retinopathy as a presentation of systemic lupus erythematosus, …) and the nature of retinal conditions (ischemic ocular syndrome, or central retinal vein occlusion, amyloidosis, inherited conditions like retinitis pigmentosa, autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV), etc.…) that may mimic them is represented. Careful review of past uveitis history, current medications and recent vaccinations, detailed examination of signs of past or present inflammation, eventually genetic testing and/ or multimodal retinal imaging (like fluorescein angiography, EDI-OCT, OCT-angiography for lupus Purtscher-like retinopathy evaluation, or ICG for central serous retinopathy, or retinal amyloid angiopathy) may aid in correct diagnosis.

Face‐down positioning or posturing after vitrectomy for macula‐involving rhegmatogenous retinal detachments

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

The primary objective of this review is to determine whether face‐down positioning reduces the risk of retinal displacement following pars plana vitrectomy (PPV) and gas tamponade for macula‐involving rhegmatogenous retinal detachment (RRD).

Whitish Outer Retinal Spots in Retinal Detachment: Longitudinal Follow-up, Multimodal Imaging, and Clinical Utility

PURPOSE

To characterize the poorly understood phenomenon of whitish outer retinal spots that occasionally appear in retinal detachment (RD) DESIGN: Retrospective, consecutive case series SUBJECTS: Patients with RDs that had ophthalmoscopically-visible whitish outer retinal spots METHODS: All RDs with whitish outer retinal spots identified by one examiner over a 4-year interval were identified, and records were retrospectively reviewed.

MAIN OUTCOME MEASURES

Clinical and surgical observations, photography, and OCT RESULTS: Whitish outer retinal spots were visualized in 51 occurrences of RD: 45 in rhegmatogenous RDs (RRDs), 5 in tractional RDs (TRDs), and 1 in exudative RD (ERD). In RRDs the spots usually formed an arcuate band located between the causative retinal break and attached retina. However, 6 RRDs had spots located between a peripheral gutter of subretinal fluid (SRF) and attached retina. In 11 eyes, the spots were observed to appear over time and/or propagate to areas of detached retina more distal to the break. The spots corresponded to hyperreflective foci in the ellipsoid/interdigitation layers on OCT. The spots were isofluorescent on fluorescein angiography. The average duration of symptoms prior to surgical repair was 27.7 days. In 7 of 23 eyes surgically repaired by the author, the distribution of the spots assisted in localizing an occult retinal break. The spots sometimes appeared or persisted in areas of residual SRF but invariably resolved after retinal reattachment.

CONCLUSIONS

Whitish outer retinal spots can occur in all types of RD, not just RRDs. Observation of the spots can help to date an RD as subacute and should prompt surgery. Because the spots occur in distributions that reflect the path of spread of subretinal fluid, their position can be used to localize causative retinal breaks.

Two Patients with Atypical Choroidal Detachment

Serous choroidal detachment that is caused by rhegmatogenous retinal detachment (RRD) may present a significant diagnostic challenge as delayed recognition and repair of the underlying RRD can severely impact the final anatomical and visual outcome. We report 2 consecutive patients with atypical choroidal detachments who were later found to have underlying RRDs. A 71-year-old female presented with a 1-week history of painful vision loss and floaters in the left eye. Examination revealed choroidal detachments in the nasal and temporal periphery and an overlying retinal detachment with shifting subretinal fluid. However, no retinal breaks were identified. An extensive laboratory workup and imaging of the orbits were unrevealing. She was treated with 80 mg oral prednisone daily for 2 weeks with subsequent resolution of the choroidals but persistence of the retinal detachment. Similarly, a 52-year-old male presented with a 3-week history of flashes and floaters followed by painful vision loss in the left eye 1 day prior to presentation. He had hand motion vision OS and the intraocular pressure was undetectable by hand-held tonometry OS. Dense brunescent cataract prevented adequate viewing of the posterior pole. B-scan ultrasonography revealed a funnel retinal detachment, with homogenous choroidal echogenicities suggestive of hemorrhagic choroidal detachment. Extensive laboratory workup was unrevealing. The patient was started on 60 mg oral prednisone and re-evaluated every 2 days, but ultrasonography revealed persistence of the choroidal detachment after 1 week. The diagnosis of RRD with an associated choroidal detachment should be considered, even in the absence of an identifiable causative retinal break.

Japan-Retinal Detachment Registry Report I: preoperative findings in eyes with primary retinal detachment

PURPOSE

To report the demographics and clinical characteristics of patients with a primary retinal detachment (RD).

DESIGN

Prospective cohort study by a registry design.

PARTICIPANTS

Patients with RD treated at vitreoretinal sub-specialty institutions in Japan from February 2016 to March 2017.

METHODS

Descriptive statistics for the primary RD, and multivariable ordered logistic regression and multiple linear regression analyses were performed.

RESULTS

3178 eyes of 3178 cases were analyzed. The interval from onset to surgery was significantly shorter in patients in the 40-year age group than in other age groups except for the 50-year age group (P<0.05, Steel-Dwass test). The proportion of complex cases was significantly higher in the 10-year, 70-year, and 80+ year age groups than in the 40 and 50-year age groups (P<0.05, Steel-Dwass test). The size of RD was significantly associated with the male sex (odds ratio, 1.29; 95% confidence interval [CI], 1.07 to 1.56; P=0.0085) and the interval from onset to surgery (odds ratio, 1.03 95% CI, 1.01 to 1.04; P=0.0014). Low IOPs in eyes with RD were significantly associated with an older age (-0.24 mmHg/10 years, 95% CI, -0.32 to -0.16], P<0.0001) and larger RD area (-0.91 mmHg/quadrant, 95% CI, [-1.06 to -0.76], P <0.0001).

CONCLUSION

Profile and clinical characteristics of patients with a primary RD were not exactly the same as previous reports. A preoperative low IOP was associated with several ocular factors while the area of RD was associated not only with ocular but with social factors as well.

Auricular acupressure for myopia in children and adolescents: A systematic review

OBJECTIVES

To identify and assess the evidence showing the efficacy of auricular acupressure alone for myopia in children and adolescents.

METHODS

Randomized controlled trials (RCTs) that were published until March 2019 in Pubmed, Web of Science, OVID, Foreign Medical Literature Retrieval Service, China Knowledge Resource Integrated Database, The Chinese Biological Medicine Database, Wanfang Database, and Chongqing VIP Information were searched. The quality of RCTs was assessed using the Cochrane risk of bias assessment tool.

RESULTS

Ten RCTs were included to be qualitatively summarized, of which 5 studies qualified for the meta-analysis of the efficacy rate in treating myopia. This review demonstrated that auricular acupressure alone was more effective than eye-drops treatment, eye exercise, and was the just as effective as needle acupuncture.

CONCLUSIONS

Auricular acupressure could slow the progression of myopia in children and adolescents. However, there is a need for further studies with higher methodological quality and sufficient follow-up.

A 21-Year Study of Vitreoretinal Surgery for Aphakic Retinal Detachment: Long-Term Surgical Outcomes and Complications

PURPOSE

To determine the characteristics and outcomes of primary retinal detachment (RD) surgery in aphakic patients.

DESIGN

Retrospective case series.

PARTICIPANTS

Sixty eyes with primary aphakic RD (ARD) in 51 patients.

METHODS

A consecutive series of patients who underwent vitreoretinal surgery for primary rhegmatogenous ARD was analyzed retrospectively between 1997 and 2018 at Moorfields Eye Hospital.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), surgical outcomes, and complications.

RESULTS

Mean BCVA improved from 1.31 to 1.08 logarithm of the minimum angle of resolution (logMAR; P = 0.081) over a mean follow-up period of 8.2 years. Macula-off retinal detachments showed significantly improved BCVA from 1.72 to 1.1 logMAR (P = 0.007). Mean age was 38.8 years, and the most common cause of aphakia was congenital cataract surgery (55%). The macula was attached in 45% eyes, and grade C proliferative vitreoretinopathy (PVR) was present in 12%. Operations performed were vitrectomy (88%), combined vitrectomy and scleral buckle (8%), and encirclement (3%). The final anatomic success rate was 88%, and PVR was a significant predictor of redetachment (P = 0.03; odds ratio, 20.7; 95% confidence interval, 2.8-152.2). Raised intraocular pressure was the most common postoperative complication at 30%, with a rate of de novo postoperative glaucoma of 6.7% at final follow-up.

CONCLUSIONS

We report high rates of primary and overall anatomic success for surgery in ARD surgery. Grade C PVR was a positive predictor for surgical failure. Final visual outcomes were limited by ocular comorbidity, and we report significant improved visual outcomes for macula-off ARD.

Vitreoretinal surgery on the fellow eye: A retrospective analysis of 18 years of surgical data from a tertiary center in England

Purpose:

To determine the long-term incidence of fellow-eye surgical involvement in patients who have undergone first-eye vitreoretinal (VR) surgery for a variety of indications. This was a single-institution retrospective, consecutive series.

Methods:

Eighteen years of electronic surgical data were reviewed at our institution. All patients having surgery for the following indications were included: rhegmatogenous retinal detachment (RRD), macular hole (MH), epiretinal membrane (ERM), proliferative diabetic retinopathy (PDR), vitritis, and dropped nucleus. Primary outcome was the cumulative incidence of fellow-eye surgery at 10 years by Kaplan–Meier analysis.

Results:

Total follow-up was 29,629 patient-years. Cumulative incidence (± standard error) of fellow-eye surgery at 10 years was 7.2% ± 0.6% for RRD, 9.1% ± 1.3% for ERM, 7.5% ± 1.8% for MH, 30.6% ± 1.9% for PDR, 13.7% ± 2.9% for vitritis, and 2.8% ± 1.6% for dropped nuclei. The hazard for second-eye surgery was greatest in the early postoperative period after first-eye surgery for all indications. For RRD, the hazard was 2.7% ± 0.3% at year 1, 1.1% ± 0.2% at year 2, and 0.5% ± 0.2% at year 5. Risk factors for fellow-eye involvement for RRD were younger age (P < 0.001) and male gender (P < 0.01).

Conclusion:

We report the long-term risk of fellow-eye involvement in various VR pathologies, which is important in counseling patients regarding their risks as well as planning service provision.

Retinal Detachment after Cataract Surgery: Retrospective Study of 57 Cases

The Authors studied the characteristics and the surgical results of 57 pseudophakic patients operated on between January 1989 and June 1991 for primary retinal detachment at the Department of Ophthalmology of the “Hotel Dieu de Paris Hospital”, with a postoperative follow-up of at least six months. The series included 23 eyes with posterior chamber IOL, 33 eyes with anterior chamber IOL. The ECCE with PC IOL group and the ICCE with AC IOL group had the same anatomical and visual prognosis.

Clinically undetected retinal breaks causing retinal detachment: A review of options for management

The successful detection of retinal breaks is a critical step in rhegmatogenous retinal detachment surgery in order to prevent persistent/recurrent retinal detachments. Not all retinal breaks causing retinal detachments are obvious. Retinal breaks may be obscured by opacities that are either anterior segment related, lens related, or posterior segment related. Rules to identify breaks based on subretinal fluid configuration are more difficult to apply in pseudophakic, aphakic, and scleral buckle encircled eyes-and in eyes with repeat detachments and those with proliferative vitreoretinopathy. Exudative detachments exhibit characteristic features and must be ruled out. A thorough clinical examination preoperatively is important even if a vitrectomy is planned. We review the incidence and causes of undetected breaks, along with preoperative/clinical issues that may hinder break detection. We review the literature with respect to investigative approaches and techniques that are available to the vitreoretinal surgeon when primary breaks remain clinically undetected during the preoperative examination. We broadly divide the surgical approaches into ones where the surgeon utilizes techniques to pursue actively a search for breaks versus adopting a purely speculative approach. Advantages and disadvantages of various techniques are appraised. Intuitively one might argue that an encircling scleral buckle combined with vitrectomy would give higher single operation success than pars plana vitrectomy alone because "undetected" retinal breaks would be addressed by a 360° plombage. We could not confirm this concept. Newer techniques, such as pars plana vitrectomy augmented with dye extrusion or endoscopic-assisted pars plana vitrectomy, show encouraging results. Technological advances such as intraoperative optical coherence tomography will also help to broaden the vitreoretinal surgeon's armamentarium. At this time, there is no gold standard in terms of the recommended approach, and this is reflected in the many options that are available for management. The surgeon must consider the benefits versus the risk of their preferred approach.

Scleral buckling with a noncontact wide-angle viewing system in the management of rhegmatogenous retinal detachment

PURPOSE

To introduce a modified scleral buckling surgery using noncontact wide-angle viewing system and intraocular illumination in the treatment of rhegmatogenous retinal detachment (RRD) without proliferative retinopathy.

METHODS

A modified scleral buckling surgery using noncontact wide-angle viewing system with a 25-G optic fiber through sclerotomy site was performed in 22 eyes of 22 patients with RRD. Twelve women and 10 men were included. The mean age was 49.23 ± 15.19 years. The mean refraction of myopia was -4 D (range -3 to -7 D). The mean duration of RRD was 6.64 ± 3.14 days. The preoperative best-corrected visual acuity (BCVA) ranged from 0.02 to 0.8. Mean follow-up was 9.59 ± 2.24 months. Proliferative retinopathy was grade A in 8 eyes and grade B in 14 eyes.

RESULTS

This surgery was performed successfully and retinal attachment was achieved in all eyes at the final follow-up. The postoperative BCVA increased in all eyes. No complication was encountered related to this technique.

CONCLUSIONS

This modified scleral buckling surgery brings a panoramic and upright view and easy surgical maneuvers. It may be an additional approach for the management of RRD.

Pneumatic Retinopexy for Rhegmatogenous Retinal Detachment in Pseudophakia

PURPOSE

To identify the characteristics predictive of unfavorable outcomes for pneumatic retinopexy (PR) in the repair of pseudophakic rhegmatogenous retinal detachments (RD).

METHODS

A retrospective chart review was performed at a single institution to identify patients who underwent PR in pseudophakic eyes. Pre- and postoperative data were reviewed and analyzed to evaluate predictive factors of failure.

RESULTS

Forty-four patients met the study criteria. PR was successful in 23 (52.3%) patients. The failed cases underwent scleral buckles, vitrectomies, or both. A retinal tear located outside the superior four clock hours was a significant predictor of PR failure. At six months post-intervention, the failure and success groups were statistically similar for vision and rate of reattachment.

CONCLUSIONS

Modified criteria for PR in pseudophakia may include cases with retinal breaks within the superior four clock hours. If further surgery is required, the final vision and anatomic reattachment are not disadvantaged by the initial PR procedure.

Tamponade or filling effect: changes of forces in myopic eyes

Myopia is the most common ocular abnormality. Its high and growing prevalence has contributed to a recent surge in surgical interest in the disorder, since retinal detachment in eyes with high myopia differs from that in emmetropic eyes or eyes with low myopia. The myopic eye, because of its specific anatomy, poses special challenges that need to be overcome to ensure the appropriate use of vitreous substitutes. However, intraocular tamponades have shown great potential for revolutionizing retinal detachment surgery and vitreomacular surgery in general in myopic eyes. We provide an updated review of the clinical use of vitreous substitutes in the myopic eye, paying particular attention to analyzing the ideal function of endotamponade agents and comparing the effects of these agents on the physical and biological properties of the eye.

The pattern and distribution of retinal breaks in eyes with rhegmatogenous retinal detachment

PURPOSE

To identify which presenting features of rhegmatogenous retinal detachment (RRD) suggest the presence of multiple retinal breaks and to ascertain relevant patterns in retinal break location.

DESIGN

Observational single-center case series.

METHODS

We collected data from 851 eyes undergoing surgery for RRD between January 2001 and September 2011. Data recorded included patient demographics; extent of RRD; and the size, location, and number of retinal breaks. Statistical regression was used to identify risk factors for the presence of multiple breaks and to analyze patterns in break location.

RESULTS

Of 851 patients, 7 patients were excluded because of insufficient data. Of 844 patients analyzed, 60% were male. The mean age was 62 years. Three hundred twenty-eight eyes (38.9%) had solitary breaks, whereas 58.8% had breaks in more than 1 quadrant. The superotemporal (ST) quadrant was involved most frequently (582 eyes; 69%). The superonasal and inferotemporal quadrants were involved in 341 (40%) and 274 (32%) eyes, respectively. The inferonasal (IN) quadrant was involved the least frequently (144 eyes; 17%). Of 328 eyes with only 1 break, it was most likely to be in the ST quadrant (182 eyes; 55%) and least likely to be in the IN quadrant (19 eyes; 6%). The risk of having multiple breaks was highest for patients with inferior breaks. Eyes with an IN quadrant break were almost twice as likely to harbor further breaks compared with eyes with an ST quadrant break. Vitreous hemorrhage at presentation was associated with larger breaks. ST quadrant breaks were most likely to be detached (92%), whereas IN quadrant breaks were least likely to be detached (60%).

CONCLUSIONS

The ST quadrant is the most likely location for retinal breaks, the most frequently involved quadrant in eyes with solitary breaks, and has the highest proportion of detached breaks. By contrast, the IN quadrant is the least likely location for a break, the least frequently involved quadrant in eyes with solitary breaks, and the most likely location for attached breaks. The presence of an inferior (especially IN quadrant) retinal break should raise suspicion that the eye harbors further breaks.

Giant retinal tears

A giant retinal tear (GRT) is a full-thickness neurosensory retinal break that extends circumferentially around the retina for three or more clock hours in the presence of a posteriorly detached vitreous. Its incidence in large population-based studies has been estimated as 1.5% of rhegmatogenous retinal detachments, with a significant male preponderance, and bilaterality in 12.8%. Most GRTs are idiopathic, with trauma, hereditary vitreoretinopathies and high myopia each being causative in decreasing frequency. The vast majority of GRTs are currently managed with a pars plana vitrectomy; the use of adjunctive circumferential scleral buckling is debated, but no studies have shown a clear anatomical or visual advantage with its use. Similarly, silicone oil tamponade does not influence long-term outcomes when compared with gas. Primary and final retinal reattachment rates are achieved in 88% and 95% of patients, respectively. Even when the retina remains attached, however, visual recovery may be limited. Furthermore, fellow eyes of patients with a GRT are at higher risk of developing retinal tears and retinal detachment. Prophylactic treatment under these circumstances may be considered but there is no firm evidence of its efficacy at the present time.

Pars plana vitrectomy for rhegmatogenous retinal detachment associated with benign retinal tumors

Two patients with known histories of benign retinal tumors presented with rhegmatogenous retinal detachments (RRD) in the same eye. One had a retinocytoma and presenting vision of 20/50, while the other had congenital hypertrophy of the retinal pigment epithelium and vision of 20/30. Both had subretinal fluid accumulation in a configuration consistent with a retinal break near the tumor; however, no breaks were detected on examination or intraoperatively. Pars plana vitrectomy (PPV), drainage retinotomy, fluid-air exchange, barrier laser around the tumor, and gas tamponade successfully reattached the retina in both cases. After 12 and 6 months of follow-up, respectively, final vision was 20/25 and the retina remained attached. RRD may be associated with benign retinal tumors presumably with microscopic breaks at the margins. In these cases, PPV, drainage retinotomy, fluid-air exchange, endolaser around the tumor, and gas tamponade can be effective for treatment.

Characteristics of rhegmatogenous retinal detachment and their relationship to visual outcome

AIMS

To examine pre-operative characteristics of rhegmatogenous retinal detachment (RRD) and their relationship to visual acuity (VA) following surgery.

METHODS

Review of prospectively completed electronic database. Baseline characteristics, retinal drawings and outcomes were analysed.

RESULTS

In all, 847 eyes from 847 patients with a mean age of 62.2 years, 60% males, and 56% right eyes were studied. Mean follow-up was 9.6 months. Preoperative VA correlated with final VA (r(2)=0.21, P<0.0001). Median postoperative VA was 6/9 (Logmar 0.18, quartiles=0.0-0.48) and was significantly related to anatomical success: 70.15% achieved 0.18 or better with fully attached retina and primary success, whereas only 8.33% achieved this when the retina was not fully attached at final follow-up (failure) (P<0.0001). Univariate analysis found multiple variables associated with achieving 0.18 postoperative vision, however, multivariate analysis revealed only primary anatomical success with surgery; absence of proliferative vitreo-retinopathy (PVR), better-presenting VA and fewer quadrants of detachment were associated with a better visual outcome (r(2)=0.26, P<0.0001). Patients with a clinically attached fovea achieved better vision than patients with a clinically detached fovea, independent of the visual loss duration. With foveal detachment however, postoperative VA was better in patients with 1-3 days of visual loss compared with 4-6 days (P=0.013).

CONCLUSIONS

Failure of primary surgery, PVR, extensive RRD and poor-presenting VA are risk factors for poorer visual outcome following surgery for RRD. Fovea off RRD at presentation achieved poorer postoperative VA than fovea attached and visual outcome was poorer when there was a longer duration of visual symptoms.

Characteristics of rhegmatogenous retinal detachment in pseudophakic and phakic eyes

AIMS

To investigate whether pseudophakic and phakic rhegmatogenous retinal detachment (RRD) patterns differ.

METHODS

Retrospective review of electronic database of patients, aged 50 years or over, presenting to our vitreoretinal service. Data included baseline characteristics, digital drawings, and outcomes. Retinal drawings were analysed in a masked fashion for site, size, and number of retinal breaks. Comparisons were made between the following groups and subgroups: pseudophakic eyes, phakic eyes, phakic eyes with cataract, and phakic eyes without cataract.

RESULTS

Of 500 eyes included, 146 were pseudophakic; 177 of the phakic eyes had cataract. The following were significant by univariate analysis: pseudophakic patients were older than phakic patients in general, but the same age as patients with cataract; in the pseudophakic group, there were lower proportions of females and of patients presenting with vitreous haemorrhage or with large or superotemporal breaks; higher proportions of pseudophakic eyes had small breaks and inferonasal breaks. Some differences remained significant when comparing pseudophakia eyes with cataract. Multivariate analysis comparing pseudophakia with phakia confirmed a lower chance in pseudophakia of large breaks, vitreous haemorrhage and superotemporal breaks, but higher chance of detached inferior breaks. Some variables were age dependent.

CONCLUSION

Differences were found between pseudophakic and phakic RRD patterns. These suggest special pathogenetic mechanisms in pseudophakic retinal detachment, which could help explain increased incidences of RRD after cataract surgery.

Endoscope-assisted vitrectomy in the management of pseudophakic and aphakic retinal detachments with undetected retinal breaks

PURPOSE

To demonstrate the efficacy of endoscope-assisted pars plana vitrectomy in treating patients with retinal detachments with no retinal breaks detected preoperatively.

METHODS

Medical records of 20 consecutive eyes with pseudophakic and aphakic rhegmatogenous retinal detachments but without retinal breaks detected preoperatively were reviewed. In each case, endoscope-assisted pars plana vitrectomy was performed.

RESULTS

In 19 of 20 eyes, breaks were identified with the help of an endoscope during surgery. To treat breaks, transscleral cryopexy or endolaser was performed under the endoscopic vision. The retina was reattached after a single surgery in all cases. No serious complication related to the operation was experienced.

CONCLUSION

Endoscope-assisted vitrectomy is useful in the management of pseudophakic and aphakic retinal detachments with undetected retinal breaks preoperatively.

Myopia-related optic disc and retinal changes in adolescent children from singapore

PURPOSE

To examine early myopia-related optic disc and retinal changes in a Singapore Chinese adolescent sample without confounding ocular or systemic disease.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

Children aged 12 to 16 years at a follow-up visit for Singapore Cohort Study of Risk Factors for Myopia.

METHODS

Detailed eye examinations, including cycloplegic autorefraction and contact biometry, were performed. Retinal photographs were acquired using nonmydriatic retinal photography among children who attended follow-up examinations in 2006, and were graded for myopia-related optic disc signs and macular changes by a single experienced grader. Optic nerve head parameters were measured adjusting for camera and ocular magnification with appropriate formulae.

MAIN OUTCOME MEASURES

Optic disc changes (tilt, beta peripapillary atrophy [β-PPA], and optic nerve parameters) and macular changes (staphyloma, lacquer cracks, Fuchs' spot, and chorioretinal atrophy).

RESULTS

Retinal photography data were available for 1227 children (median age, 14 years; range 12-16). Tilted optic discs were found in 454 subjects (37%), and were associated with myopic spherical equivalent refractions (-3.6 diopters [D] vs -1.3 D; P<0.0001), higher cylindrical error (0.9 vs 0.7 D; P = 0.0001) and longer axial length (24.93 vs 23.96 mm; P<0.0001). The pattern of distribution of the axes of the tilted discs and corneal curvature were similar (P = 0.4). All linear optic nerve parameters, except vertical disc diameter (P = 0.15), were significantly smaller in eyes with than without tilted discs (P <0.001) after adjusting for confounders. Apart from 20 cases, all eyes with tilted optic discs had associated β-PPA. We identified only 1 case each (0.1% prevalence) of staphyloma and lacquer cracks in this sample.

CONCLUSIONS

In this Asian adolescent population, tilted optic discs were highly prevalent, in contrast with the lower prevalence reported in Caucasian populations. Eyes with tilted discs tended to have smaller optic cups with smaller cup-to-disc ratios, and were associated with myopic refraction, higher astigmatism, and longer axial length. There were similar patterns of distribution between the axis of disc tilt and the axis of corneal curvature, which could have embryologic origins. In contrast with optic disc changes, myopic macular changes were rare in this age group, suggesting that these changes may develop later in life.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

The predisposing pathology and clinical characteristics in the Scottish retinal detachment study

PURPOSE

To describe the predisposing pathology and clinical features of all incident cases of rhegmatogenous retinal detachment (RRD) recruited in Scotland during a 2-year period.

DESIGN

Prospective surveillance study of incident cases of RRD.

PARTICIPANTS

All incident cases of RRD recruited as part of the Scottish Retinal Detachment Study.

METHODS

During a 2-year period, we coordinated a comprehensive system in which every case of primary RRD presenting to 1 of 6 vitreoretinal surgical sites in Scotland was examined and approached for study inclusion.

MAIN OUTCOME MEASURES

Rhegmatogenous retinal detachment incidence, predisposing features, and clinical characteristics.

RESULTS

A total of 1202 cases were recruited. Detailed clinical information was available on 1130 (94%) of cases. By causative break, the proportions of RRD were horseshoe tear (HST) associated with posterior vitreous detachment (PVD) in 86.2%, giant retinal tear (GRT) and PVD in 1.3%, non-PVD round hole (RH) in 4.9%, retinal dialysis in 5.9%, and retinoschisis RRD in 1.6%. One in 10 cases reported significant ocular trauma. One in 5 cases were pseudophakic. Round hole RRD more frequently presented with multiple retinal breaks compared with HST RRD (67.8% vs. 48.7%; P = 0.003). In PVD-associated RRD, 56.1% (95% confidence interval [CI], 53.8-58.3) of breaks were identified in the superotemporal retina. In non-PVD RRD, 54.6% (95% CI, 47.9-61.1) of breaks were inferotemporal, followed by superotemporal in 34.9% (95% CI, 28.7-41.5). Lattice degeneration was present in 18.7% of affected eyes and more common in RH RRD (35.7%) than in HST RRD (19.3%) (P = 0.003). Seven percent reported an affected first-degree relative, and these cases were significantly more myopic than nonfamilial cases.

CONCLUSIONS

More than 85% of RRD cases are associated with PVD and related tractional tears. Non-PVD RH RRD occurred in younger and more myopic individuals. The majority of cases are caused by more than 1 retinal break, and the macula is affected in more than 50% at presentation. Ocular trauma, previous cataract surgery, family history, and lattice degeneration are important predisposing features.

The scleral buckling of primary rhegmatogenous retinal detachment under the surgical microscope

BACKGROUND AND OBJECTIVE

To analyze the feasibility of performing scleral buckle under the surgical microscope without using the indirect ophthalmoscope.

PATIENTS AND METHODS

Data came from 342 eyes of 339 patients with primary rhegmatogenous retinal detachment (RRD) that were suitable for scleral buckling. All surgeries were performed under the surgical microscope including examination and localization of retinal breaks, scleral buckling, and retinal cryotherapy.

RESULTS

During intraoperative examination, additional retinal breaks were found in 39 cases. Among 36 eyes in which a retinal break was not observed pre-operatively, 23 cases had retinal breaks detected during surgery. The anatomic success rate after one operation was 88.9% and the final success rate was 98.0%.

CONCLUSION

Scleral buckling of RRD with equatorial or pre-equatorial breaks can be easily done under the surgical microscope, which has the merits that the surgeon's view is a clear upright image, manipulations are simple, and good surgical results can be obtained.

Recent trends in the management of rhegmatogenous retinal detachment

It has been nearly a century since Jules Gonin performed the first intervention for rhegmatogenous retinal detachment, trans-scleral cautery, achieving successful outcomes in close to 50% of his cases. With the introduction of alternative surgical approaches in the last half-century, including Charles Schepens' scleral buckle technique and Robert Machemer's pars plana vitrectomy, the surgical success rates have risen to close to 90%. Nonetheless, despite dramatic progress in the success of reattachment surgeries, reasonable disagreement exists as to which approach (or combination of approaches) is the best form of surgical intervention for patients with rhegmatogenous retinal detachments. In this review, the authors summarize the current knowledge of retinal detachment, and examine emerging results from the first large scale, prospective, randomized, controlled clinical trials addressing the efficacy of these surgical approaches for retinal detachment, with the hope of identifying the most appropriate (evidence-based) therapeutic intervention for the treatment of rhegmatogenous retinal detachment.

[Surgical results of retinal detachment with unseen retinal breaks]

BACKGROUND

The treatment of retinal detachment (RD) with unseen breaks has not been clearly defined. The aim of this study was to evaluate surgical results of these RDs using two different techniques.

PATIENTS AND METHODS

We conducted a retrospective study including consecutively operated RDs in our department between 2001 and 2006. Twenty-two RDs were identified. In eight eyes (36.4%), conventional scleral buckling was performed (with or without subretinal fluid drainage). In 14 eyes (63.6%), vitrectomy associated with cryopexy or endolaser impact was performed. Circumferential buckling was achieved in ten cases.

RESULTS

These operated patients account for 2.5% of the RDs followed up in our department between January 2001 and June 2006 (887 patients). The eyes were predominantly pseudophakic (86.4%), with inferior RD (59.1%). The patients had described functional signs for a mean of 56 days (2-240 days). Sixteen eyes (73%) were reattached after the primary procedure. The primary reattachment rates at 1 month were 37.5% in the scleral buckling group versus 86.4% in the vitrectomized group. The final retinal reattachment rate was 86.4%.

CONCLUSIONS

In our study, the situation where breaks are unseen during retinal detachment surgery is uncommon (2.5%), occurring most often with inferior retinal detachment in pseudophakic eyes. This seems to indicate better retina reattachment after vitrectomy associated with a circumferential buckling in first intention. However, a study including a larger number of patients would be necessary to confirm our results.

Rhegmatogenous Retinal Detachment After LASIK for Myopia

PURPOSE

To report the characteristics and incidence of rhegmatogenous retinal detachment in myopic eyes after LASIK.

METHODS

The medical records of 49 patients with rhegmatogenous retinal detachment after LASIK were reviewed. The incidence of rhegmatogenous retinal detachment after LASIK was determined and potential risk factors were evaluated.

RESULTS

LASIK was performed on 59,424 eyes with spherical equivalent refraction (SE) ranging from -0.75 to -26.50 diopters (D) (mean: -6.10 +/- 3.5 D). Forty-nine eyes developed rhegmatogenous retinal detachment between 1.5 and 76 months (mean: 27.3 +/- 21.7 months) after LASIK. The mean preoperative refractive error in these eyes was -8.6 +/- 3.9 D. Mean age of these patients was 38.2 +/- 11.2 years. Thirty-five (71.4%) patients were male. The cumulative incidence of rhegmatogenous retinal detachment was 0.082% (95% confidence interval [CI]: 0.061-0.109), and the yearly incidence was 0.032% (95% CI: 0.023-0.042) after LASIK. The most frequent location of the retinal breaks was the superior temporal quadrant (22.7%). Male sex, older age, and higher preoperative myopia were significantly related to the incidence of rhegmatogenous retinal detachment after LASIK (P<.001).

CONCLUSIONS

Based on the results of this study, following the treatment of high-risk peripheral retinal lesions, LASIK did not appear to be an additional risk factor for the development of rhegmatogenous retinal detachment after LASIK in our patients; however, patients should be informed of the possibility of this complication as a consequence of myopia. Patients who are male, older in age, and have high myopia preoperatively may be at increased risk.

Les décollements de rétine rhegmatogènes inférieurs : particularités cliniques et thérapeutiques

PURPOSE

To determine the epidemiological and clinical factors involved in inferior rhegmatogenous retinal detachments and to propose a therapeutic plan.

PATIENTS AND METHODS

A retrospective case note review of 173 patients (175 eyes), 11-89 years old, who had been operated on for inferior retinal detachment over a 13-year period between 1990 and 2003.

RESULTS

The retinal reattachment rate after initial surgery was 79.5%, the final anatomical success rate was 81.5%. Scleral buckling surgery was used for the primary repair of rhegmatogenous retinal detachments in 111 cases and it was successful in 81 cases. Fifty-eight patients underwent vitrectomy with internal silicone oil tamponade. Anatomical success was obtained in 55 cases (94.8%) without recurrence. Endocular surgery allowed surgeons to find missed causal tear in 76% of cases. Mixed surgery was undertaken in four cases, with three good results. Visual acuity improved in 81% of cases, remained unchanged in 15% of cases, and deteriorated in 4% of cases. The mean final visual acuity ranged from 2.5 to 3/10, while it was only 1/20 before surgery. The mean improvement in visual acuity was 2.5 lines. The mean follow-up in our study was 13+/-11 months.

CONCLUSION

Inferior retinal detachment usually occurred in young myopic or old pseudophakic subjects. These patients are characterized by the absence of tears. Vitrectomy in primary repair with inferior retinal detachment improves their anatomical and functional prognosis.

Management of Retinal Detachment When No Break Is Found

OBJECTIVE

To review the results of 2 different surgical approaches in the management of primary rhegmatogenous retinal detachments (RDs) with undetected retinal breaks.

DESIGN

Retrospective, consecutive, interventional case series.

PARTICIPANTS

Medical records of 44 patients with uncomplicated macula-involving primary rhegmatogenous-appearing RDs, but without retinal breaks detected preoperatively or intraoperatively, were reviewed.

METHODS

All study patients were operated by the same surgeon between 1989 and 2004 using 2 approaches: 26 (59%) patients underwent a scleral buckling procedure (SBP) with or without subretinal fluid drainage, whereas 18 (41%) patients underwent scleral buckling combined with pars plana vitrectomy (PPV), fluid-gas exchange, and broad application of endolaser.

MAIN OUTCOME MEASURES

Single operation and final postoperative anatomic success, and 2-month postoperative and final best-corrected visual acuity (VA) (negative logarithm of the minimum angle of resolution [logMAR]).

RESULTS

Mean preoperative VAs were 1.73 logMAR units (median, 1.60; range, 0.48-2.60) in the combined surgery group and 1.52 logMAR units (median, 1.30; range, 0.30-2.60) in the scleral buckling group. Neither preoperative (P = 0.33), 2-month postoperative (P = 0.53), best-corrected (P = 0.98), nor final (P = 0.46) mean VA showed any statistically significant differences between the 2 treatment groups. A single operation reattachment rate of 72% (13/18 cases) was achieved in the combined surgery group, compared with 61.5% (16/26 cases) in the scleral buckling group (P = 0.17, log rank test). Immediate anatomic success rates were 89% after combined treatment and 38.5% after scleral buckling alone (P = 0.002). At the final visit, the retina was attached in 15 (83.3%) patients who received the combined treatment and in 22 (84.6%) patients who underwent scleral buckling (P = 0.900). Intraoperative subretinal hemorrhage occurred in 1 (5.6%) patient from the combined surgery group and in 2 (7.7%) patients from the scleral buckling group. Retinal incarceration in the drainage sclerotomy occurred in 1 (3.8%) case during the SBP. Proliferative vitreoretinopathy sufficient to require reoperation developed in 1 (5.6%) eye of the combined surgery group and in 3 (11.5%) eyes of the scleral buckling group.

CONCLUSIONS

Scleral buckling is as effective in the management of uncomplicated rhegmatogenous RDs with undetected breaks as is surgery combining scleral buckling and PPV.

The risk of fellow eyes in patients with rhegmatogenous retinal detachment

PURPOSE OF REVIEW

A review of the current literature regarding the risk of nontraumatic rhegmatogenous retinal detachment in the fellow eye and prophylaxis of predisposing lesions is presented.

RECENT FINDINGS

Although reports vary in study design and inclusion/exclusion criteria, the risk of retinal detachment in fellow eyes is similar to prior findings. Studies on prophylactic therapy also treated different cohorts. This makes drawing definitive conclusions difficult.

SUMMARY

Rhegmatogenous retinal detachment poses a significant threat to the fellow eye. Risk factors specifically relevant to the fellow eye are discussed. There is insufficient evidence to recommend prophylactic therapy for prevention of retinal detachment in the fellow eye. To date, no prospective, randomized clinical trial on the prevention of retinal detachment in the fellow eye has been published.

Frequency and predictors of retinal detachment after pediatric cataract surgery without primary intraocular lens implantation

PURPOSE

To determine the frequency and to identify predictors of retinal detachment after pediatric cataract surgery without primary intraocular lens implantation.

METHODS

Retrospective review at an eye hospital identified 1017 eyes among 579 patients who underwent limbal-approach surgery without primary IOL implantation at age < or =16 years for cataract unassociated with other ocular abnormalities aside from microcornea. Patients had a minimum of 2 years postoperative follow-up. The outcome measure was the presence or absence of postcataract surgery retinal detachment, and analyses were performed on patients' eyes with adjustment for intrasubject correlation.

RESULTS

Mean postcataract surgery follow-up was 6.8 +/- 3.6 years (range, 2.0 to 18.3 years). Retinal detachment developed in 33 (3.2%) of the 1017 patients' eyes and was diagnosed at a mean of 6.8 +/- 4.4 years postcataract surgery (range, 0.4 to 14.8 years). Multivariable Cox proportional hazards regression analysis with adjustment for intrasubject correlation identified an aphakic refractive error more myopic than the age-adjusted aphakic norm [hazard ratio (HR), 5.9; 95% confidence interval (CI), 1.9 to 18.0; P = 0.002] and postcataract surgery wound dehiscence (HR, 15.4; 95% CI, 2.2 to 108.5; P = 0.006) as predictors of retinal detachment; a primary posterior capsulotomy/anterior vitrectomy procedure was not predictive of retinal detachment.

CONCLUSIONS

Retinal detachment is infrequent following pediatric cataract surgery without primary IOL implantation, at least with short-term follow-up. A postoperative aphakic refractive error more myopic (less hyperopic) than the age-adjusted aphakic norm is predictive of this complication.

Proliferative vitreoretinopathy--at what risk is the fellow eye?

PURPOSE

To find out if patients with proliferative vitreoretinopathy (PVR) due to complicated retinal detachment are at risk to acquire the same disease or other vision-threatening retinal abnormalities in the fellow eye. To furthermore assess in what time-period they appear and if subgroups of patients have special risks.

METHODS

100 consecutive PVR-patients were studied retrospectively. 21 patients with PVR graded lower than C3, traumatic PVR, diabetic retinopathy or congenital vitreoretinal diseases were excluded. Age, gender, best-corrected visual acuity at the first and last visit, refraction, ocular disease in both eyes and observation-time were recorded.

RESULTS

After a mean follow-up of 8.5 years, 42 of 79 patients (53.4%) showed vision-threatening abnormalities in their fellow eyes: among them, 9 patients (11.4%) had PVR, 13 (16%) simple retinal detachments and 14 (17.3%) retinal breaks. Abnormalities in the fellow eye did not develop after a certain time following surgery of the primary eye; 71.4% appeared within 5 years. Aphakic and pseudophakic patients had retinal breaks significantly more often (p = 0.011) than phakic patients. Myopia did not increase the risk for any abnormality. Men developed retinal detachment (p = 0.037) and PVR (p = 0.025) significantly more often than women.

CONCLUSION

Patients with PVR have a greater than 50% risk of developing vision-threatening retinal abnormalities in their fellow eye. Because of this increased risk, these patients need regularly-scheduled long-term follow-up.

SUMMARY STATEMENT

Patients with PVR have a greater than 50% risk of developing vision-threatening retinal abnormalities in their fellow eye and a 37% risk to develop PVR from rhegmatogenous retinal detachment. More than two thirds of abnormalities in the fellow eye developed within five years of surgery of the primary eye.

Clinical Characteristics and Surgical Outcomes of Pseudophakic and Aphakic Retinal Detachments

We retrospectively evaluated the clinical characteristics and surgical outcomes of 20 pseudophakic retinal detachment (RD) patients (20 eyes) and 17 aphakic RD patients (17 eyes). Males were predominated in both groups. The time interval between cataract extraction and RD was 31 months on average in the pseudophakic group, 32 months with intact posterior capsule and 27 months with ruptured posterior capsule, and 148 months in the aphakic group. In 50% of cases with ruptured posterior capsule in the pseudophakic group, RD occurred within 1 year. The anatomic success rate was 95% in the pseudophakic group and 88% in the aphakic group. The most common cause of failure was the development of proliferative vitreoretinopathy. Visual acuities more than 20/40 after RD surgery were found in 13 pseudophakic (65%) and 6 aphakic (36%) eyes. Aphakic patients were more inclined to have silent RD than pseudophakic patients because of their poor visual acuity. Post-operative follow-up is required especially for the first 1 year in cases of damaged posterior capsule due to the high incidence of RD during this period.

Pseudophakic retinal detachment

Pseudophakic retinal detachment is a rare, but potentially serious, complication of cataract surgery. The incidence of pseudophakic retinal detachment following current surgical techniques of cataract extraction, including extracapsular cataract extraction by nuclear expression and phacoemulsification, is lower than that found after intracapsular cataract extraction. The risk of pseudophakic retinal detachment appears to be increased in myopic patients, in those patients in whom vitreous loss had occurred at the time of cataract surgery, and in patients undergoing Nd:YAG posterior capsulotomy. Most cases present to the clinician when the macula is already detached and the central vision is affected. When evaluating patients with pseudophakic retinal detachment, the fundal view is often impaired by anterior or posterior capsular opacification, reflections related to the intraocular lens, or poor mydriasis. Scleral buckling, pneumatic retinopexy, and primary pars plana vitrectomy, with or without combined scleral buckling, are the surgical techniques used to treat pseudophakic retinal detachment. Anatomical success rates are high after vitreo-retinal surgery for pseudophakic retinal detachment, although a smaller proportion of patients recover good vision following surgery.

Rhegmatogenous retinal detachment and uveitis

PURPOSE

To evaluate the frequency, high-risk factors, and visual prognosis of rhegmatogenous retinal detachment (RRD) in patients with uveitis.

DESIGN

Retrospective case-control study.

PARTICIPANTS

We included 1387 consecutive patients with uveitis who consulted our uveitis clinic from January 1990 through December 1997 of whom 43 patients (46 eyes) with RRD were identified. The retinal detachment (RD) controls were 212 consecutive patients with RRD (221 eyes, first occurrence of RD, not associated with uveitis) who were admitted for surgery in the period from April 1999 to April 2000. The uveitis control group consisted of 150 age-matched patients (210 eyes) selected from the entire uveitis series.

INTERVENTION

Retrospective analysis of clinical data.

MAIN OUTCOME MEASURES

The presence of RRD and eventual risk factors for RRD, such as myopia, retinal lattice degeneration, prior intraocular surgery, anatomic location of uveitis, its specific diagnosis, and clinical manifestations. Furthermore, the surgical and nonsurgical outcomes of RRD, as well as the results of various treatment regimens, were analyzed.

RESULTS

RRD was identified in 3.1% of the patients with uveitis. RRD was most frequently associated with panuveitis (6.6%). RRD was associated more frequently with infectious (7.6%) than noninfectious uveitis (2.1%). At the onset of RRD, uveitis was active in most (46%) affected eyes. Proliferative vitreoretinopathy was present in 30% of the uveitic RRD eyes at presentation in contrast to 12% of the RRD control eyes. In uveitic RRD, the retina was reattached in 59% of eyes with a single operation; the final anatomic reattachment rate was 88%. Finally, a visual acuity of less than 20/200 was present in 71% of the uveitic RRD eyes, 10% of which had no light perception.

CONCLUSIONS

We discovered a high prevalence of RRD in patients with active panuveitis and infectious uveitis and document that uveitis in itself is a risk factor for the development of RRD. The visual prognosis of RRD in uveitis was poor because of the uveitis itself and the frequent development of proliferative vitreoretinopathy.

Management of rhegmatogenous retinal detachment without detectable breaks

PURPOSE

To evaluate the causes of failure to find retinal breaks, the anatomical and functional outcomes of patients with rhegmatogenous retinal detachment (RD) without detectable breaks (Group I), to compare the results with detectable breaks (Group II).

METHODS

Forty-five out of 258 eyes that had RD without detectable breaks were analysed retrospectively.

RESULTS

The causes of failure to find retinal breaks were aphakia/pseudophakia in 22 eyes, small pupil without any eye disease in four eyes, corneal opacity in two eyes, cataract in two eyes, vitreous haze in two eyes, choroidal detachment in one eye, and unknown cause in 12 eyes. After a single scleral buckling procedure, anatomical re-attachment of the retina successfully occurred in 62.2% of group I and 78.9% of group II patients. After repeated surgery, final anatomical success rates were 87.2% and 90.2%, respectively. The best corrected visual acuity was 6/60 or better in 53.9% in Group I and 52.5% in Group II.

CONCLUSION

The main cause of failure to find the retinal break was aphakia or pseudophakia. Although the rates of retinal reattachment in eyes without detectable breaks in primary buckling surgery was lower than detectable breaks and reoperations were required more frequently, final success rates were satisfactory and similar in both groups.

Biostatistical analysis of pseudophakic and aphakic retinal detachments

Removal of the crystalline lens increases the risk of rhegmatogenous retinal detachment (RD) by creating changes in the ocular environment that predispose to development of retinal breaks. The evolution of cataract surgery from intracapsular cataract extraction (ICCE) to extracapsular cataract extraction (ECCE) and phacoemulsification has reduced the incidence of RD, while advances in vitreoretinal surgery have resulted in improved outcomes when retinal detachment does occur. The incidence of RD varies between 0.4-3.6% for ICCE and between 0.55-1.65% for ECCE. In eyes having undergone phacoemulsification the incidence is similar to those of ECCE and ranges between 0.75-1.65%. In this article the authors review the incidence and risk factors associated with pseudophakic and aphakic RD. The risk factors discussed include pre-operative risk factors such as age, status of the fellow eye and myopia, and surgical risk factors such as vitreous loss, posterior capsular integrity and Nd : YAG capsulotomy.

Retinal detachment in Marfan syndrome: clinical characteristics and surgical outcome

PURPOSE

To describe the clinical characteristics of retinal detachments in patients with Marfan syndrome and report the surgical outcome of vitreoretinal surgery.

METHODS

Records relating to 53 eyes of 45 patients with Marfan syndrome who underwent surgery for rhegmatogenous retinal detachment were reviewed. Of the 53 eyes, 24 (45.3%) underwent scleral buckling as the first procedure and 29 (54.7%) underwent vitrectomy surgery with scleral buckle as the first procedure. Main outcome measures included clinical characteristics of retinal detachment, reattachment rates, and functional improvement in vision.

RESULTS

Characteristic findings included total retinal detachment in 40 (75.5%) eyes, atrophic holes in 24 (45.3%) eyes, more than four retinal breaks in 21 eyes (39.6%), preequatorial and postequatorial breaks in 20 (37.7%) eyes, giant retinal tears in six (11.3%) eyes, and proliferative vitreoretinopathy (posterior, anterior, or both) in nine (17%) eyes. In 30 (56.6%) eyes, retinal breaks were located only in the temporal half of the retina. Of the 24 eyes with myopia, 13 (54.2%) had a myopic correction greater than 7 diopters. At the median follow-up of 10.7 months, complete retinal reattachment was obtained in 87.6% and 86.2% of patients undergoing scleral buckling (including additional procedures such as vitrectomy) and vitrectomy surgery, respectively. In eyes with reattached retinas, a final visual acuity of 20/200 or better was obtained in 81% of the patients after scleral buckling and in 56% of the patients after vitrectomy surgery (P = 0.07).

CONCLUSIONS

Retinal detachment in Marfan syndrome is complete in 75% of the eyes. More than half (56%) the eyes had a retinal break only in the temporal half of the retina, and 83% had at least a break in the temporal half of the retina. Currently available vitreoretinal surgical techniques result in successful reattachment of the retina in approximately 86% of the eyes.

The expanding role of primary pars plana vitrectomy in the treatment of rhegmatogenous noncomplicated retinal detachment

The surgical management of rhegmatogenous retinal detachment has evolved dramatically during the past 2 decades. Investigators have introduced and refined alternative techniques to scleral buckling surgery including pneumatic retinopexy and primary pars plana vitrectomy (PPV). Rapid parallel developments in instrumentation, including wide-angle viewing systems, perfluorocarbon liquids, novel vitrectomy machines, intraocular tamponades, and endolaser photocoagulators have led to increasing sophistication in primary PPV surgical techniques for the treatment of rhegmatogenous uncomplicated retinal detachment. However, the precise role of primary PPV in new uncomplicated retinal detachment remains debatable owing to the lack of controlled randomized trials. This article examines primary vitrectomy treatment for rhegmatogenous uncomplicated retinal detachment and presents the specific types of retinal detachments for which primary PPV may be optimal, according to personal and reported results, the surgical instrumentation and technique, as well as the complications and limitations of this surgical method.

Phacoemulsification and lens implantation after scleral buckling surgery

PURPOSE

To determine the intraoperative and postoperative complications and best-corrected visual acuity outcomes of eyes undergoing phacoemulsification and intraocular lens implantation after retinal detachment repair by the scleral buckling technique.

METHODS

The charts of all patients who underwent phacoemulsification and intraocular lens implantation between July 1991 and May 1998 in two surgical practices were reviewed to identify eyes with a history of retinal detachment repaired by the scleral buckling technique. Eyes with a history of pars plana vitrectomy were excluded. Demographic and surgical data, preoperative and postoperative best-corrected visual acuity, and intraoperative and postoperative complications were recorded.

RESULTS

We identified 34 eyes of 32 patients. The mean interval from retinal detachment repair to phacoemulsification was 12.4 years. The mean interval from phacoemulsification to final examination was 20 months. Risk factors for retinal detachment included isolated myopia (82%), myopia with lattice retinal degeneration (5.9%), and myopia with trauma (8.8%). One eye (2.9%) had no identifiable risk factors. Final best-corrected visual acuity of 20/40 or better was attained in 29 (85%) of 34 eyes and 20/20 or better in 18 (53%) of the eyes. Of the five eyes with the lowest best-corrected visual acuity, three had a macula-off retinal detachment; one had a posterior capsule opacity, epiretinal membrane, and corneal edema secondary to ocular ischemia; and one had advanced glaucoma. All five eyes still experienced an improvement in best-corrected visual acuity. With regard to complications, one eye had a posterior capsular tear with vitreous loss and another developed a postoperative retinal tear. Posterior capsule opacification requiring laser capsulotomy developed in 13 eyes (38%). No eye developed a retinal redetachment.

CONCLUSION

Phacoemulsification and intraocular lens implantation can be performed safely after scleral buckling surgery and excellent best-corrected visual acuity results can be attained in most eyes. No modification of surgical technique is necessary. No retinal redetachment occurred in this series.