Clinical features and surgical management of retinal detachment secondary to round retinal holes

Retinal detachment risk in the fellow eyes of patients presenting with retinal tears in more than two quadrants

Literature discussing fellow eye risk in patients with rhegmatogenous retinal detachment secondary to posterior vitreous detachment (PVD) is limited, particularly in subgroups where this risk may be greater than the general population. In this retrospective consecutive case series with 107 study patients, the risk of retinal tears in fellow eyes of patients with horseshoe tears in three or more quadrants of their presenting eye, secondary to PVD, was 81%. The fellow eye risk is high in this subgroup of patients, and it is important to inform them to seek prompt attention when symptoms of PVD develop in their fellow eye.

Retinal detachment

Retinal detachment (RD) occurs when the neurosensory retina, the neurovascular tissue responsible for phototransduction, is separated from the underlying retinal pigment epithelium (RPE). Given the importance of the RPE for optimal retinal function, RD invariably leads to decreased vision. There are three main types of RD: rhegmatogenous, tractional and exudative (also termed serous) RD. In rhegmatogenous RD, one or more retinal breaks enable vitreous fluid to enter the subretinal space and separate the neurosensory retina from the RPE. In tractional RD, preretinal, intraretinal or subretinal membranes contract and exert tangential forces and elevate the retina from the underlying RPE. Finally, in exudative RD, an underlying inflammatory condition, vascular abnormality or the presence of a tumour causes exudative fluid to accumulate in the subretinal space, exceeding the osmotic pump function of the RPE. The surgical management of RD usually involves pars plana vitrectomy, scleral buckling or pneumatic retinopexy. The approach taken often depends on patient characteristics as well as on practitioner experience and clinical judgement. Advances in surgical technology and continued innovation have improved outcomes for many patients. However, even if retinal re-attachment is achieved, some patients still experience decreased vision or other visual symptoms, such as metamorphopsia, that diminish their quality of life. Continued research in the areas of neuroprotection and retinal biology as well as continued surgical innovation are necessary to enhance therapeutic options and outcomes for these patients.

Posterior vitreous detachment and retinal tear - a prospective study of community referrals

BACKGROUND

Retinal tears (RT) from posterior vitreous detachment (PVD) are an important and treatable cause of rhegmatogenous retinal detachment (RRD). Better understanding of the risk of RT from PVD will help plan urgent eye care.

METHODS

Prospective observational case series over two years. Patients presenting to their optometrist, family doctor or emergency department with flashes and floaters were directed to a research clinic. History and examination, including slit-lamp biomicroscopy (SLB) and indentation indirect ophthalmoscopy (IIO), were performed by a single investigator, with two month follow-up for patients with confirmed PVD. Main outcome measures were incidence of PVD, RT, and RRD.

RESULTS

1010 patients were recruited. 896 (89%) patients had PVD at first assessment, of which 89 (8.8% of total cohort, 9.9% of PVD eyes) had RT and 8 had RRD. 21 (3%) of the remaining PVD patients developed RT in the subsequent two months and a further 9 (11%) patients with RT at initial assessment developed further tears by two months. 7 (0.7%) had asymptomatic RT in the fellow eye. 15% of RT were only visible on IIO and not SLB. Weiss ring was absent in 32% of eyes with RT. Patients with RT or RRD were more likely than 'PVD-only' eyes to have blurred or missing vision (p < 0.001), have higher rate of blue-green cataracts (p < 0.001), and longer axial lengths (p < 0.05).

CONCLUSIONS AND RELEVANCE

This large, prospective study demonstrates a 9.9% rate of RT or RRD at the time of PVD, and emphasises the importance of IIO examination.

A Novel Transcriptome Approach to the Investigation of the Molecular Pathology of Vitreous and Retinal Detachment

Retinal detachment (RD) is one of the most common, sight-threatening ocular conditions requiring emergency intervention. Posterior vitreous detachment (PVD) occurs in the majority of an aging population whereby the vitreous body separates from the retina. It is well established that PVD is the common precursor to the most common forms of RD; however, it remains unknown why in most individuals PVD will cause no/few complications (physiological PVD) but in a small percentage will cause retinal tears and detachment (pathological PVD). Despite over 100 years of scientific research, the anatomical definitions of PVD and its pathogenesis remain controversial. Recent research has identified a novel cell population (laminocyte), present at significantly higher numbers in pathological PVD when compared to physiological PVD. We review and summarise the seven distinct clinical sub-groups of retinal breaks and focus on the role of the laminocyte in those secondary to PVD and the transcriptomic profile of this unique cell. Provisional whole transcriptome analysis using bulk RNA-Seq shows marked differentially expressed genes when comparing physiological PVD with PVD associated with RD. The limitations of bulk RNA-Seq are considered and the potential to address these using spatial transcriptomics are discussed. Understanding the pathogenesis of PVD-related retinal tears will provide a baseline for the development of novel therapeutic targets and prophylactic treatments.

A Comparative Study of Traditional Scleral Buckling to a New Technique: Guarded Light Pipe with Heads-Up Three-Dimensional Visualization

Purpose

The guarded light pipe is a recently described alternative endoillumination technique to chandelier illumination. We sought to compare the outcomes of scleral buckling (SB) under indirect ophthalmoscopy (ID) to heads-up three-dimensional visualization with a guarded light pipe (3DGLP).

Methods

A retrospective comparative study was performed, including 47 eyes that underwent SB for rhegmatogenous retinal detachment (RRD) repair with either traditional ID (n = 31) or 3DGLP (n = 16).

Results

The single surgery anatomic success rate was 87.0% in the ID group and 87.5% in the 3DGLP group. The final anatomic success rate was 100% in both groups. The median (interquartile range) post-operative logMAR was 0.10 (0.0–0.20) in the ID group and 0.08 (0.02–0.69) in the 3DGLP group (p = 0.51). The median operative time was 107 (94–123) minutes in the ID group and 100 (90–111) minutes in the 3DGLP group (p = 0.25). Among eyes that underwent subretinal fluid drainage, the operative time was significantly longer in the ID group compared to the 3DGLP group, 113 (100–135) minutes vs 93 (85–111) minutes (p = 0.035). There were no post-operative complications in the ID group and one complication of self-resolving vitreous hemorrhage associated with a malfunctioning cryoprobe in the 3DGLP group (p = 0.34). There were no cases of post-operative cataract progression in either group.

Conclusion

Compared to traditional SB, 3DGLP improves ergonomics and educational value with similar anatomical, visual, intra and post-operative outcomes and may result in shorter operative time in cases requiring subretinal fluid drainage.

Scleral Buckling: A Look at the Past, Present and Future in View of Recent Findings on the Importance of Photoreceptor Re-Alignment Following Retinal Re-Attachment

Scleral buckling (SB) remains an important technique to master for those interested in treating rhegmatogenous retinal detachment (RRD). Several ways to repair RRD include pneumatic retinopexy (PR), pars plana vitrectomy (PPV), SB or a combination of these. There is a growing worldwide trend that favors PPV as the preferred method for retinal reattachment of primary uncomplicated RRD. Reimbursement issues, operating room access, and technological advances in PPV that improve retinal visualization and less exposure to SB during fellowship training may explain this trend. As the number of SB cases decreases over time, there is a risk that SB becomes a dying art and surgeons in training may not be trained in SB. SB is preferred in eyes with no posterior vitreous detachment and retinal dialysis. SB with minimal gas vitrectomy may be indicated for eyes with inferior pathology. Non-contact wide-angled visualization with chandelier assisted SB may be well suited for teaching new generations of aspiring vitreoretinal surgeons. Its functional and anatomic results compare favorably with conventional SB for primary uncomplicated primary RRD. The main advantage of this technique is the improved visualization even through small pupils. Better visualization ensures treatment of all breaks while avoiding complications during drainage of subretinal fluid and a safer placement of intrascleral sutures for scleral fixation of the buckling element. Recordings of the procedure are easily performed, allowing the surgeons involved to review the case and learn from it. The main disadvantage is the cost involved with the chandelier and the need to have a microscope or a 3D system with a wide angle viewing system. Photoreceptor re-alignment following retinal re-attachment is an important determinant of the post-operative functional outcomes. Different methods of retinal re-attachment apparently result in different degrees of photoreceptor re-alignment. SB may hold an advantage over PPV in this regard.

Rhegmatogenous retinal detachment repair-does age, sex, and lens status make a difference?

PURPOSE

To analyze the correlation between lens status, age, and sex in the epidemiology and success rates of rhegmatogenous retinal detachment (RRD) surgery.

METHODS

The files of all consecutive patients undergoing vitreoretinal surgery for uncomplicated RRD between Jan 2005 und Dec 2020 were retrospectively reviewed. Successful outcome was defined as no retinal redetachment occurring within 3 months after surgery.

RESULTS

5502 eyes with uncomplicated primary RRD were included. Mean age of the patients was 61.1 years (± 13.6 SD). In the age group over 40 years, a male predominance was found. The percentage of pseudophakic RRD increased from 25 to 40% during the 15 years observation period. In the age group 50 to 69 years, patients with pseudophakic detachments were male in 786 out of 1079 cases (72.9%). In the same age group, 1285 of 2110 (60.9%) patients with phakic RRD were male. Overall, primary success rate after one procedure was 91.2% (5018 of 5502). In the phakic eyes, the primary success rate was higher in those eyes that underwent combined phacovitrectomy (93.0%), compared to those without simultaneous cataract surgery (88.7%; p = 0.002).

CONCLUSION

The ratio of male and female patients with RRD varies between age groups. The proportion of pseudophakic RRD has increased within 15 years. The male predominance in RRD is stronger in pseudophakic than in phakic eyes. In phakic eyes with RRD, a combined phacovitrectomy yielded better anatomical results.

Characteristics and Seasonal Variations of Rhegmatogenous Retinal Detachment in the Eastern Black Sea Region of Turkey: 8-Year Results

Objectives:

To assess seasonal variations in the incidence of rhegmatogenous retinal detachment (RRD) in the Eastern Black Sea region of Turkey.

Materials and Methods:

Patients presenting due to primary RRD to a university hospital operating as a reference clinic in the region between 2011 and 2018 were evaluated retrospectively. Patients’ ages, sex, affected eye, and presentation times were recorded. Years were divided into months, quarters, seasons, and half-year periods, and these periods were analyzed in terms of differences in patient numbers.

Results:

Two hundred eighty-one eyes of 276 patients meeting the study criteria were included. The patients’ mean age was 60.2 years, and the male:female ratio was 1.35:1. Right and left eye rates were similar. Detachments were most common (49.4%) in the upper temporal quadrant. Eighty-nine patients (31.6%) had undergone uncomplicated phacoemulsification surgery a mean 2.7 years previously. The mean annual case number was 35.13±5.43, and no statistically significant variation was determined in case numbers by year (p=0.558). Analysis of all years revealed a monthly mean case number of 23.42±4.4, with the highest number of cases, 29 (10.3%), being seen in September and the lowest number, 13 (4.7%), in December. No statistically significant monthly variation was determined (p=0.613). Similarly, no statistically significant variation was observed in case numbers analyzed by quarter, season, or half-year (p>0.05).

Conclusion:

The incidence of cases of uncomplicated RRD does not exhibit seasonal variation in our region. We also think that since 31.6% had a history of cataract surgery, patients undergoing phacoemulsification surgery, even if uncomplicated, should be periodically assessed for detachment.

Montgomery and informed consent during Covid-19: Pneumatic retinopexy versus pars plana vitrectomy or scleral buckling for retinal detachment repair

Recent reports suggest that the use of an outpatient-based procedure (pneumatic retinopexy, PR) for retinal detachment repair should be encouraged within the UK, especially in light of Covid-19 and possible restrictions/competing demands on access to operating theatres. It is therefore essential that patients receive comprehensive information about the risks and benefits of this approach compared with a formal surgical repair either by pars plana vitrectomy (PPV) and/or scleral buckling (SB). We report a retrospective case series of retinal detachments (RD) satisfying the strict selection criteria for PR but who were managed with formal surgery. Single-operation success rate for PPV/SB at six months follow-up was 93.8% in our study, higher than published primary success rates for PR (60-80%). When counselling patients for possible PR, the ease, speed and potentially reduced co-morbidity of an outpatient-based procedure needs to be balanced against its significantly higher failure rate in comparison with primary PPV/SB.

Rhegmatogenous retinal detachment: a review of current practice in diagnosis and management

Rhegmatogenous retinal detachment (RRD) is a common condition with an increasing incidence, related to the ageing demographics of many populations and the rising global prevalence of myopia, both well known risk factors. Previously untreatable, RRD now achieves primary surgical success rates of over 80%-90% with complex cases also amenable to treatment. The optimal management for RRD attracts much debate with the main options of pneumatic retinopexy, scleral buckling and vitrectomy all having their proponents based on surgeon experience and preference, case mix and equipment availability. The aim of this review is to provide an overview for the non-retina specialist that will aid and inform their understanding and discussions with patients. We review the incidence and pathogenesis of RRD, present a systematic approach to diagnosis and treatment with special consideration to managing the fellow eye and summarise surgical success and visual recovery following different surgical options.

WIDEFIELD SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHY IMAGING OF PERIPHERAL ROUND RETINAL HOLES WITH OR WITHOUT RETINAL DETACHMENT

PURPOSE

To describe the widefield spectral-domain optical coherence tomography features of peripheral round retinal holes, with or without associated retinal detachment (RD).

METHODS

Retrospective, observational study of 28 eyes with peripheral round retinal holes, with and without RD. Patients underwent imaging with a widefield 50-degree spectral-domain optical coherence tomography (Heidelberg Engineering, Germany) and Optos ultra-widefield imaging systems (Optos, United Kingdom).

RESULTS

Vitreous attachment at the site of the retinal hole was detected in 27/28 (96.4%) cases. Cases were split into three groups: RHs with RD (n = 12); RHs with subretinal fluid (n = 5), and flat RHs (n = 11), with minimal or no subretinal fluid. 91.6% retinal holes associated with subretinal fluid or RD had vitreous attachment at the site of the hole. Eighty percent had vitreous attachment at both edges of the retinal hole, in a U-shape configuration, which appeared to exert traction. By contrast, flat retinal holes had visible vitreous attachment only at one edge of the retinal hole in 45.4%.

CONCLUSION

Vitreous attachment was commonly seen at the site of round retinal holes. Vitreous attachment at both edges of the retinal hole in a U-shape configuration was more commonly seen at holes associated with subretinal fluid or RD.

Preoperative factors to select vitrectomy or scleral buckling for retinal detachment in microincision vitrectomy era

BACKGROUND

To determine the preoperative factors associated with selecting scleral buckling (SB) or pars plana vitrectomy (PPV) to treat rhegmatogenous retinal detachments (RRDs) in the era of microincision vitrectomy surgery.

METHODS

A nationwide, multicenter, observational study in the Japan Retinal Detachment Registry was done. From February 2016 to March 2017, 3446 cases were registered, and 3219 among them were analyzed. The factors related to the patient or surgeon were selected; the surgeon's factor included years of experience, number of cases registered, and current activity. The odds ratio (OR) for factors associated with SB or PPV was estimated by a mixed logistic regression model.

RESULTS

SB was selected in 24.2% (779/3219), PPV was in 71.5% (2238/3219), and PPV+SB was in 6.3% (202/3219). Multivariate analysis showed that age [< 70 years old, OR 4.27, 95% confidence interval (CI) 2.34-7.79, P < 0.001], visual acuity [1.0+ (OR 7.41, 95% CI 3.47-15.82, P < 0.001)], pseudo-phakia (OR 4.83, 95%CI 2.11-10.56, P < 0.001), retinal tear (OR 6.92, 95% CI 4.83-9.92, P < 0.001), breaks at/near the vitreous base (OR 8.07, 95% CI 3.50-18.62, P < 0.001), 90+° retinal tear (OR 108.24, 95% CI 7.44-1574.34, P < 0.001), and number of breaks 4+ (OR 3.15, 95% CI 1.95-5.09, P < 0.001), were significantly associated with selecting PPV over SB. The surgeons' activity defined as the number of cases experienced during the registry period was related to the selection of PPV (OR 3.83, 95% CI 2.11-6.93, P < 0.001).

CONCLUSIONS

The choice of PPV for the RRD was associated not only with patients' preoperative factors but also the surgeon's activity. Active surgeons selected PPV more than SB.

Scleral buckling-a brief historical overview and current indications

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

Relationships between retinal break locations and the shapes of the detachments

Purpose

Detecting primary breaks and confirming detachment preoperatively are important. Lincoff stated that retinal detachments progress according to gravity; his law has become popular. We evaluated Lincoff’s law with a slight modification to determine whether it remains suitable for present cases independent of refractive error and previous cataract surgery.

Patients and methods

Group 1 included superior region detachments not exceeding the 12 o’clock midline; the original break was within 1 1/2 clock hours of the highest detachment border. Group 2 included shallow inferior detachment; the original break corresponded to the more spread side of the 6 o’clock midline. Group 3 detachments were beyond 12 o’clock; the original break was within a triangle with a 12 o’clock apex (A) or within 1 1/2 hours of 12 o’clock (B); (A) and (B) were stated in the original report. Another five classifications were applied for small numbers of detachments. Consecutive initial rhegmatogenous retinal detachment surgery patients were included; medical records and detachment charts were examined. Eyes were classified into categories and rates were calculated. Eyes that had never undergone previous cataract surgery besides those in which the macula remained attached were divided into groups at a −6 D cutoff (Groups 1, 2, and 3[B]); we compared groups in each category. We compared phakic eyes, pseudophakic eyes, and eyes ruptured at the posterior capsule (Groups 1, 2, and 3[B]).

Results

Finally, 747 eyes were categorized. In Groups 1, 2, 3(A), and 3(B), corresponding rates were 92, 86, 70, and 89%, respectively. Between the above and below −6 D groups, there was no significant difference in rate in any category. There were no significant differences between phakic, pseudophakic, and ruptured eyes.

Conclusion

Lincoff’s law was suitable for the present cases and independent of refractive error and previous cataract surgery.

Intraocular currents, Bernoulli's principle and non-drainage scleral buckling for rhegmatogenous retinal detachment

For many years, it is not fully understood how non-drainage scleral buckling surgery brings about spontaneous reattachment of the detached retina when retinal breaks remain open at the end of surgery. Various explanations have been put forward, but none more interesting than the effect of fluid currents associated with eye movements. One such explanation involved the physics of the Bernoulli's principle. Daniel Bernoulli was an eighteenth century Swiss mathematician and he described an equation based on the conservation of energy. The sum of pressure energy, potential energy and kinetic energy remains constant. Bernoulli's equation usually applies to closed system such as the flow of fluid through pipes. When fluid flows through a constriction, the speed of fluid increases, the kinetic energy increases. If there was no change in elevation (potential energy), then the increase in kinetic energy must be accompanied by a decrease in pressure energy. In ophthalmic surgery, the Bernoulli's effect is the basis for venturi pumps that drive vitrectomy and phacoemulsification machines. This essay expounds on how Bernoulli's effect might be relevant to scleral buckling for retinal detachment repair. In the era when vitrectomy is increasing the primary surgical operation for retinal detachment, the pervasive advice is to emphasise the importance of patient adopting head posture and remaining still postoperatively. The exception is non-drainage scleral buckling surgery. Early postoperative mobilisation may be vital to achieve reattachment.

SCLERAL BUCKLE SURGERY FOR PRIMARY RETINAL DETACHMENT WITHOUT POSTERIOR VITREOUS DETACHMENT

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictive factors for postoperative visual function of primary chronic rhegmatogenous retinal detachment after scleral buckling

AIM

To evaluate predictive factors for postoperative visual function of primary chronic rhegmatgenous retinal detachment (RRD) after sclera buckling (SB).

METHODS

Totally 48 patients (51 eyes) with primary chronic RRD were included in this prospective interventional clinical cases study, which underwent SB alone from June 2008 to December 2014. Age, sex, symptoms duration, detached extension, retinal hole position, size, type, fovea on/off, proliferative vitreoretinopathy (PVR), posterior vitreous detachment (PVD), baseline best corrected visual acuity (BCVA), operative duration, follow up duration, final BCVA were measured. Pearson correlation analysis, Spearman correlation analysis and multivariate linear stepwise regression were used to confirm predictive factors for better final visual acuity. Student's t-test, Wilcoxon two-sample test, Chi-square test and logistic stepwise regression were used to confirm predictive factors for better vision improvement.

RESULTS

Baseline BCVA was 0.8313±0.6911 logMAR and final BCVA was 0.4761±0.4956 logMAR. Primary surgical success rate was 92.16% (47/51). Correlation analyses revealed shorter symptoms duration (r=0.3850, P=0.0053), less detached area (r=0.5489, P<0.0001), fovea (r=0.4605, P=0.0007), no PVR (r=0.3138, P=0.0250), better baseline BCVA (r=0.7291, P<0.0001), shorter operative duration (r=0.3233, P=0.0207) and longer follow up (r=-0.3358, P=0.0160) were related with better final BCVA, while independent predictive factors were better baseline BCVA [partial R-square (PR(2))=0.5316, P<0.0001], shorter symptoms duration (PR(2)=0.0609, P=0.0101), longer follow up duration (PR(2)=0.0278, P=0.0477) and shorter operative duration (PR(2)=0.0338, P=0.0350). Patients with vision improvement took up 49.02% (25/51). Univariate and multivariate analyses both revealed predictive factors for better vision improvement were better baseline vision [odds ratio (OR) =50.369, P=0.0041] and longer follow up duration (OR=1.144, P=0.0067).

CONCLUSION

Independent predictive factors for better visual outcome of primary chronic RRD after SB are better baseline BCVA, shorter symptoms duration, shorter operative duration and longer follow up duration, while independent predictive factors for better vision improvement after operation are better baseline vision and longer follow up duration.

Persistent subfoveolar fluid following retinal detachment surgery: an SD-OCT guided study on the incidence, aetiological associations, and natural history

PURPOSE

To investigate the incidence and natural history of persistent subfoveolar fluid (PSF) following surgery for macular off rhegmatogenous retinal detachment and the effect of PSF on photoreceptor structure and final visual acuity.

METHODS

Retrospective study of 61 cases with post-operative optical coherence tomography (OCT) performed within 12 weeks of surgery. Based on aetiology, cases were categorized into tractional retinal tears (TRT) group or atrophic round holes and dialyses (RHD) group to investigate the incidence and duration of PSF. A Kaplan-Meier graph was plotted to compare survival time of subfoveolar fluid for both groups. Following secondary reclassification of cases into those with and without PSF, the effect of PSF on final visual acuity and photoreceptor structure was investigated with Mann-Whitney U-test used for comparison. Spearman's correlation testing was used to probe associations between time to recorded resolution of PSF with final visual acuity and photoreceptor structure.

RESULTS

Incidence of PSF was greater in the RHD group and persisted for longer compared with TRT group. No detectable adverse effect of PSF on final visual acuity was seen however an individual case of severe photoreceptor atrophy was observed. No significant correlation was found between the time to recorded resolution of PSF and the final visual acuity or to photoreceptor grading scores.

CONCLUSIONS

A difference in incidence of PSF was detected between the aetiological groups. PSF was ubiquitous and slow to resolve in the RHD group. Most cases of PSF resolve without adverse sequelae; however, progressive photoreceptor atrophy and sub-optimal visual outcome may result in a minority.

Risk factors related to chronic rhegmatogenous retinal detachment

AIM

To evaluate the clinical factors related to chronic rhegmatogenous retinal detachment (RRD).

METHODS

A retrospective case-control study. A total of 103 consecutive patients (103 eyes) with primary RRD were studied to evaluate the clinical factors related to chronic RRD.

RESULTS

Chi-square test was used to sift out the following associated factors with chronic RRD: younger patients (P=0.0028), better preoperative best corrected visual acuity (BCVA, P=0.0316), atrophic retinal break (P<0.0001), inferior retinal break (P<0.0001), smaller break (P=0.0005); then the independent risk factors related to chronic RRD was determined by stepwise logistic regression analysis as following: atrophic retinal break (odds ratio (OR)=7.997, P=0.007), inferior retinal break (OR=14.127, P<0.0001) and better preoperative BCVA (OR=1.636 P<0.0722) .

CONCLUSION

Atrophic retinal break, inferior retinal break and better preoperative BCVA are the independent risk factors related to chronic RRD.

Retrospective Study of Rhegmatogenous Retinal Detachments Secondary to round Retinal Holes

Purpose

The authors aim to analyze the incidence, characteristics, surgical management, and outcome of patients presenting to St Thomas' Hospital with a rhegmatogenous retinal detachment secondary to atrophic round retinal holes.

Methods

This is a retrospective collation of patients presenting to a single surgeon with a round hole–associated retinal detachment between 2001 and 2009. Specific collation of demographics, retinal detachment features, choice of management, complications, requirement for further surgery, and ultimate surgical success with final visual acuity is reported.

Results

Fifty-six patients with a retinal detachment secondary to a round hole were identified (4.49% incidence). The cohort had a median age of 28.9 years (range 14 to 39) and a female predominance (64%). The median spherical equivalent refractive error was −5.5 diopters (range −1 to −18). The commonest quadrant with retinal holes was the inferotemporal quadrant (40% of patients). Approximately half of our cohort were identified to have lattice degeneration at any site and in either eye. The majority of patients received an external nondrainage procedure (92%) with cryotherapy (88%) and an explant (94%). Three patients required further surgery to achieve retinal reattachment and 12% required surgery for a retinal detachment in the fellow eye. At final follow-up, 78% achieved a visual acuity of 0.18 logMAR (6/12 Snellen) or better and the median final visual acuity was 0.00 logMAR (6/6 Snellen).

Conclusions

Retinal detachments secondary to round holes have consistent characteristic features (young, myopic, female, inferior detachment). Surgical management is increasingly advocated and most achieve primary surgical success with a good final visual acuity.

Prevention and control of proliferative vitreoretinopathy: primary retinal detachment surgery using silicone oil as a planned two-stage procedure in high-risk cases

AIMS

For rhegmatogenous retinal detachment, reattachment with a single procedure is associated with better visual outcomes. In the past, silicone oil has been used mostly as a last resort following failed primary surgery. This study evaluates a novel approach to patients at high risk of primary failure, using silicone tamponade as the primary stage of a planned two-stage procedure.

METHODS

We report a series of 140 eyes that underwent primary surgery for rhegmatogenous retinal detachment. Patients at higher risk of surgical failure (eg giant retinal tear, inability to posture, poor view, uncertainty of location of primary break, primary proliferative vitreoretinopathy (PVR), multiple tears with rolled posterior edges, retinoschisis/detachment, staphyloma with macular hole) were managed by a planned staged procedure using primary silicone oil tamponade. This was followed by silicone removal at a later date.

RESULTS

Fifty-four eyes underwent scleral buckling alone, with primary success in 52/54 (96%). Fifty-three eyes underwent vitrectomy and gas, achieving primary success in 50/53 (94%). Thirty-three eyes were classified high risk and managed with primary silicone. Silicone was safely removed in 22/25. In eight eyes, silicone was retained without attempt at removal. In total, primary retinal reattachment was achieved in 128 of 140 eyes (91.4%). Of these, 124 (97%) did not require long-term tamponade. Only four eyes (2.9%) developed PVR.

DISCUSSION

A planned two-stage approach to highrisk cases of retinal detachment using primary silicone oil tamponade followed by silicone removal can achieve a high primary reattachment rate with less than 3% incidence of PVR.

Scleral buckling combined with vitrectomy for the management of rhegmatogenous retinal detachment associated with inferior retinal breaks

AIM

The use of adjunctive scleral buckling during vitrectomy for retinal detachment associated with inferior breaks has been the recent focus of some debate. It has been suggested that any benefit might be outweighed by potential complications associated with buckling surgery. The purpose of this study was to compare the success rate of vitrectomy, gas, and supplementary scleral buckling with the results of two recently published case series suggesting that acceptable results in inferior break detachments can be achieved with vitrectomy and gas alone.

METHODS

A retrospective analysis of 60 consecutive patients with inferior break retinal detachments was conducted. All patients underwent vitrectomy, gas, and scleral buckling. In all cases, fellow eyes were examined under anaesthesia for retinal breaks if posterior vitreous detachment (PVD) had occurred at the time of presentation. Demographics, preoperative, and postoperative complications and outcome were recorded.

RESULTS

Primary retinal attachment at 3 months was achieved in 95% of patients. This exceeds success rates of published data of patients who underwent vitrectomy and gas without buckling (81-89%). In patients with PVD in the fellow eye, 53% had horseshoe tears and all were treated with cryopexy. No sight-threatening complications occurred, but five patients developed minor buckle-related complications postoperatively.

CONCLUSION

Supplementary scleral buckling is a safe procedure that improves and enhances primary success rates in inferior break detachments over vitrectomy and gas without buckling. There is a high rate of PVD-related breaks requiring treatment in the fellow eyes.

Characteristics of primary rhegmatogenous retinal detachment in Taiwan

PURPOSE

To investigate the epidemiological characteristics and related risk factors for primary rhegmatogenous retinal detachment (RRD) in Taiwan.

METHODS

The case-control study was based on retrospective chart review of hospital patients treated for primary RRD from 1995 to 2001, inclusively. The preoperative fundus findings and refractive status were collected for each patient. Controls were selected from a nationwide survey of visual impairment in the adult population during the same period. Risk factors for RRD were analysed by logistic regression. A total of 1032 RRD cases and 3537 controls were enrolled for the study.

RESULTS

A pronounced bipeak pattern was evident in the age distribution for primary RRD in the third and sixth decades of life. Atrophic hole with lattice degeneration was preferential to younger (20-30 years) and highly myopic individuals (-7.4+/-5 D), whereas the flap tear tended to occur in middle-aged individuals (50-60 years) and those with moderate myopia (-4.1+/-5 D). The odds ratio for primary RRD with myopia, male gender, and older age (>40 years) were 1.33/D, 2.15, and 1.69, respectively.

CONCLUSIONS

Myopia is an important RRD risk factor for young Taiwanese. The increasing prevalence of myopia has predisposed the young population to RRD.