Post-operative outcome in rhegmatogenous retinal detachment

Predictors of Vision Loss after Surgery for Macula-Sparing Rhegmatogenous Retinal Detachment

PURPOSE

To determine factors associated with loss of good vision (defined as Snellen visual acuity [VA] < 20/40) after surgery among eyes presenting with macula-on primary rhegmatogenous retinal detachment (RRD) with initial VA ≥20/40.

MATERIALS AND METHODS

Multicenter, retrospective, cohort study of eyes undergoing scleral buckle (SB), pars plana vitrectomy (PPV), or combined pars plana vitrectomy/scleral buckle (PPV/SB) for non-complex macula-on RRD with initial VA ≥20/40.

RESULTS

Among 646 eyes with macula-on RRDs with initial VA ≥20/40, 106 (16.4%) had VA <20/40 (i.e. lost good vision) at final follow-up. Eyes losing good vision had slightly worse pre-operative logMAR VA (mean 0.15 ± 0.10 [20/28]) compared to eyes that preserved good vision (mean 0.11 ± 0.10 [20/26]) (p = 0.004). RRDs extending greater than 6 clock-hours were more likely to lose good vision than smaller detachments (multivariate OR 4.57 [95% CI 1.44-14.51]; p = 0.0099). Compared to eyes repaired with SB alone, eyes undergoing PPV (multivariate OR 7.22 [95% CI 2.10-24.90]; p = 0.0017) or PPV/SB (multivariate OR 10.74 [95% CI 3.20-36.11]; p = 0.0001) were each more likely to lose good vision. Eyes requiring further RRD-related (multivariate OR 8.64 [95% CI 1.47-50.66]; p < 0.017) and non-RRD related vitreoretinal surgery (multivariate OR 14.35 [95% CI 5.39-38.21]; p <0.0001) were more likely to lose good vision.

CONCLUSION

Among macula-on RRDs, loss of good vision was associated with worse vision on presentation, vitrectomy-based procedures, greater extent of detachment, and lack of single surgery success. Understanding predictors of visual outcome in macula-on RRD repair may guide pre-operative counseling regarding visual prognosis.

Factors Associated With Good Visual Acuity Outcomes After Retinectomy in Eyes With Proliferative Vitreoretinopathy

PURPOSE

To investigate factors associated with good visual acuity (VA) following repair of rhegmatogenous retinal detachments (RD) with proliferative vitreoretinopathy (PVR) undergoing retinectomy.

DESIGN

Interventional, retrospective, case-control study.

METHODS

This single-institution study evaluated patients who underwent retinectomy during repair of RD with PVR from January 1, 2015 to December 31, 2019. A good VA cohort was identified based on a final VA ≥20/70. A 2:1 age-matched and gender-matched poor VA cohort with VA <20/70 was subsequently identified. Metrics compared between the two cohorts included time from primary and recurrent RD diagnosis to surgery, lens status, initial RD size, macula involvement, PVR grade, and size of retinectomy.

RESULTS

A total of 5355 eyes were diagnosed with primary RD during the study period, of which 345 had PVR and underwent retinectomy. The good VA cohort included 62 eyes with a mean final logMAR VA of 0.32 [Snellen 20/42], while the poor VA cohort included 119 eyes with a mean final logMAR VA of 1.54 [Snellen 20/693; P < .0001]. On multivariate analysis, smaller initial RD size (P = .0090), fewer surgeries (P = .0002), shorter time between recurrent RD diagnosis and subsequent surgeries (P = .0006), better preoperative VA (P = .0276), and pseudophakia at final visit (P = .0049) remained significant predictors of good vision.

CONCLUSION

Eyes undergoing retinectomy during repair of RD with PVR can achieve good VA outcomes. The primary modifiable factor associated with better VA was shorter delay between redetachment diagnosis and surgery, particularly in the absence of silicone oil tamponade.

Urgent Vitrectomy/Phacovitrectomy for Bullous Macula-Off Retinal Detachment: Implications for Optimal Timing of Surgery

PURPOSE

Recently, an increasing number of ophthalmologists are using vitrectomy as the first line of treatment for retinal detachment (RD). The purpose of the present study was to determine the cutoff time of duration of macular detachment (DMD) after which postoperative best corrected visual acuity (BCVA) decreases sharply in eyes treated with primary vitrectomy.

DESIGN

This was a retrospective, noncomparative, interventional case series.

METHODS

Fifty-six eyes with macula-on RD and 126 eyes with bullous macula-off RD.

RESULTS

Mean postoperative BCVA showed a statistically significant decrease when DMD exceeded 10 days (P = 0.009) with vitrectomy/phacovitrectomy as the primary mode of treatment, which was comparable to previous studies using scleral buckling. Approximately 90% (88%-93%) of eyes achieved a postoperative 20/40 BCVA when DMD was 2 days or less, after which the ratio decreased (P = 0.008) but plateaued around 40% until DMD reached 10 days. On the other hand, only 5.6% of (7/126) eyes with DMD of 3 days or less achieved a postoperative 20/20 BCVA.

CONCLUSIONS

As with scleral buckling, the mean postoperative BCVA in eyes with bullous macula-off RD treated with primary vitrectomy/phacovitrectomy dropped significantly when DMD exceeded 10 days. To achieve a good postoperative visual acuity (20/40), urgent surgery with a DMD of 2 days or less is desired. Operative repair within this period, rather than outright emergency surgery, may be appropriate for most cases.

Structural recovery of the detached macula after retinal detachment repair as assessed by optical coherence tomography

PURPOSE

To investigate correlations between preoperative and postoperative foveal microstructures in patients with macula-off rhegmatogenous retinal detachment (RRD).

METHODS

We reviewed the records of 31 eyes from 31 patients with macula-off RRD who had undergone successful re-attachment surgery. We analyzed data obtained from complete ophthalmologic examinations and optical coherence tomography (OCT) before and 9 to 12 months after surgery. All postoperative OCT measurements were taken with spectral-domain OCT, but a subset of preoperative OCT measurements were taken with time-domain OCT.

RESULTS

The mean duration of macular detachment was 15.5 ± 15.2 days, and mean preoperative best-corrected visual acuity (BCVA, logarithm of the minimum angle of resolution) was 1.03 ± 0.68. Preoperative visual acuity was correlated with retinal detachment height (p < 0.001) and the existence of intraretinal separation (IRS) along with outer layer undulation (OLU) (p = 0.022), but not with macula-off duration. The final BCVA was significantly correlated with integrity of the junction between the photoreceptor inner and outer segments (IS/OS) combined with the continuity of external limiting membrane (ELM) (p = 0.025). The presence of IRS and OLU on a detached macula were highly correlated with the final postoperative integrity of the IS/OS junction and the ELM (p = 0.017).

CONCLUSIONS

Eyes preoperatively exhibiting IRS and OLU showed a higher incidence of disruption to the photoreceptor IS/OS junction and the ELM at final follow-up. Such a close correlation between preoperative and postoperative structural changes may explain why ultimate visual recovery in such eyes is poor.

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.

How effective is macula-off retinal detachment surgery. Might good outcome be predicted?

PURPOSE

To determine factors associated with anatomical and functional outcomes of macula-off retinal detachment surgery in a modern vitreoretinal unit.

METHODS

A retrospective casenote review of 185 patients presenting with macula-off retinal detachment was performed. Demographic and ocular characteristics were determined. Logistic regression analysis was used to determine (1) the effect of these factors on visual outcome and (2) their effect on primary and final anatomical success.

RESULTS

Primary and ultimate anatomical success were achieved in 76 and 84% of cases. Patients with oil in at final follow-up were considered to be anatomical failures. Statistically significant factors predicting primary anatomical success using a multiple variable model were preoperative logMAR visual acuity, preoperative PVR and number of breaks. Preop logMAR visual acuity and duration of macular detachment were the statistically significant factors predicting ultimate success. In all, 44% of patients regained 6/12 Snellen or better with a median improvement of 0.78 logMAR. For prediction of visual outcome (in patients with no ocular comorbidity) only preoperative logMAR visual acuity achieved statistical significance (P=0.001) at the P=0.05 level.

CONCLUSION

In all, 76% of macula-off detachments may be repaired with one operation and 44% of patients regain at least 6/12 Snellen. The median logMAR acuity increment of 0.78 far exceeds that seen in cataract surgery. Preoperative visual acuity is the most important factor predicting primary and final anatomical success as well as visual outcome. Preoperative PVR, number of breaks and duration of detachment also affect outcomes.

Retinal detachment in East Africa

PURPOSE

To report the causes of retinal detachment in an African setting and the outcome after surgery.

DESIGN

Noncomparative interventional case series.

PARTICIPANTS

A total of 361 eyes in 345 patients.

METHODS

Data were collected from patients' case notes. A minimum of 2 months' follow-up was available for 254 eyes. Risk factors for poor anatomic or visual outcome were analyzed by logistic regression.

MAIN OUTCOME MEASURES

Primary anatomic success, which was defined as an attached retina at least 2 months after the initial surgery, without any additional interventions; final anatomic success, defined as an attached retina at least 2 months after the latest intervention; and visual outcome, defined as the corrected visual acuity at least 2 months after the last operation.

RESULTS

The macula was detached at presentation in 332 (91.9%) eyes. In 203 (56.2%) eyes, the retina had been detached for >1 month. Proliferative vitreoretinopathy (PVR)-grade C1 or worse-was present in 63 (17.5%) eyes. Thirty eyes (8.3%) had giant retinal tears. Ninety-five patients (27.5%) were blind (<20/400 in the better eye) at presentation. The retina was successfully reattached with 1 operation in 186 (73.2%) eyes. The most frequent cause of primary failure was missed breaks or new breaks. The final anatomic success rate in eyes observed for at least 8 weeks after the last operation was 88.2%. Giant retinal tear and PVR were significant independent predictors of anatomic failure. In eyes with successfully reattached retinas, 63.9% achieved 20/200 vision or better. Among successfully reattached macula-off detachments, risk factors for a poor visual outcome (<20/200) were macular hole, duration of retinal detachment >1 month, and poor preoperative acuity. Of 74 blind patients with 2 months' follow-up, only 23 (31.1%) remained blind at the latest follow-up.

CONCLUSIONS

Retinal detachment is a treatable cause of blindness in Africa. Despite late presentation and complex pathology, surgical repair is frequently successful and often restores navigational vision. Greater emphasis should be given to the recognition and treatment of retinal detachment in regional training programs for ophthalmologists and primary eye care workers.

Retinal detachment in developing countries

Treatment of retinal detachment has been a low priority in developing countries. It is thought to be less common in India and Africa than in Europe and N America. The aetiology and presentation of retinal detachment in the Third World are affected by genetic and environmental factors. In general, patients are more likely to present late, and complex detachments are relatively more common. Despite these problems, the results of surgery are encouraging, with more than 80% final anatomical success, and over 60% of re-attached retinas obtaining vision of 6/60 or better. The management of retinal detachment in developing countries can be improved by strengthening training programmes and by developing and equipping centres to carry out retinal surgery.

Dexamethasone concentration in the subretinal fluid after a subconjunctival injection, a peribulbar injection, or an oral dose

PURPOSE

To determine dexamethasone concentrations in the subretinal fluid of patients after a peribulbar injection, a subconjunctival injection, or an oral dose of dexamethasone and to compare the results with those of previous similar studies of dexamethasone concentrations in the vitreous.

DESIGN

Prospective, nonrandomized, comparative trial.

PARTICIPANTS

One hundred forty-eight patients with a rhegmatogenous retinal detachment.

METHODS

Fifty patients received a peribulbar injection of 5 mg dexamethasone disodium phosphate, 49 received a subconjunctival injection of 2.5 mg dexamethasone disodium phosphate, and 49 received an oral dose of 7. 5 mg dexamethasone at various time intervals before surgery. At the time of surgery, a subretinal fluid sample was taken from each patient.

MAIN OUTCOME MEASURES

The dexamethasone concentration in the subretinal fluid measured by radioimmunoassay.

RESULTS

The estimated maximum dexamethasone concentrations in the subretinal fluid after the peribulbar injection, the subconjunctival injection, and the oral dose were, respectively, 82.2 ng/ml (standard error, 17. 6), 359 ng/ml (standard error, 80.2), and 12.3 ng/ml (standard error, 1.61). Corrected for dose, the maximum dexamethasone concentrations after subconjunctival injection and peribulbar injection were, respectively, 120 (95% confidence interval, 54/180) and 13 (95% confidence interval, 6.8/20) times greater than after oral administration.

CONCLUSIONS

A subconjunctival injection of dexamethasone disodium phosphate is more effective in delivering dexamethasone into the subretinal fluid of patients with a rhegmatogenous retinal detachment compared with peribulbar injection or oral administration. The subretinal dexamethasone concentrations were higher than concentrations measured in the vitreous in previous studies with a similar setup after all three delivery methods.

Who should manage primary retinal detachments?

PURPOSE

To determine whether the outcome of primary retinal reattachment surgery in a subregion is improved by surgery being performed in a specialist vitreoretinal unit (VRU).

METHODS

A subregional, population-based, retrospective audit cycle of primary retinal reattachment surgery was conducted by independent investigators. The subregion was defined as the catchment area of a teaching hospital (TH) with a specialist VRU and three neighbouring district general hospitals (DGHs). During the initial audit period (January 1989 to December 1990), 142 cases were treated at all four hospitals: TH/VRU (83), DGH-A (15), DGH-B (13), and DGH-C (31). Policy changes after the initial audit led to primary retinal reattachment surgery being predominantly performed by the VRU. During the re-audit period (September 1995 to August 1997), 160 cases were treated at two hospitals: VRU (148) and DGH-C (12). The outcome measure employed was complete retinal reattachment after a single procedure with a minimum follow-up of 12 months.

RESULTS

The success rate for primary retinal reattachment surgery in the subregion improved from 76.1% to 88.8% (p = 0.006) following the policy changes. The success rate of the vitreoretinal specialists in the VRU (90%) was greater than the general ophthalmologists in the DGHs (ranging from 47% to 77%), despite case selection by the general ophthalmologists. The number of cases treated by the VRU increased by 156% in the 6.5 year interval between the two audits due to a widespread change in the model of care for primary retinal detachments (both within and outside the subregion). During the re-audit period, the VRU treated 348 primary retinal detachments (including referrals from outside the subregion), achieving a success rate of 86.8% with a single procedure and 97.4% with further surgery. This primary success rate included 35 cases (10%) treated by vitrectomy with silicone oil tamponade who did not undergo silicone oil removal.

CONCLUSIONS

The outcome of primary retinal reattachment surgery can be improved if surgery is performed by a specialist VRU. It is suggested that the current standard for retinal reattachment with a single procedure should be set in the region of 85% to 90%. Changing the model of care so that primary retinal reattachment surgery is predominantly performed by a specialist VRU has important resource implications.

Effects of scleral buckling on the retrobulbar haemodynamic changes

PURPOSE

This study was planned to investigate blood flow changes due to scleral buckling surgery. In addition the effects on these changes of factors related to patient characteristics and operative technique were studied.

METHODS

Central retinal artery (CRA) and ophthalmic artery (OA) blood flow velocities were studied with colour Doppler ultrasonography after scleral buckling surgery in 25 patients with unilateral rhegmatogenous retinal detachment. The effects of the patient's age, referral time, aetiological factors, operative technique, cryotherapy width and buckling distance on the haemodynamic changes were noted.

RESULTS

Buckling surgery reduces the blood flow velocities in the CRA, but affects OA blood flow less. Encircling is found to be responsible and it is greater in patients with anatomical success. Other factors do not have any significant effect on these changes.

CONCLUSIONS

Good anatomical and functional results can be achieved despite these haemodynamic changes. It must be kept in mind that these changes may cause complications in some patients and the surgery must be minimized.

Primary vitrectomy for pseudophakic and aphakic retinal detachments

PURPOSE

To evaluate primary vitrectomy for the treatment of pseudophakic and aphakic retinal detachments. Primary vitrectomy may enable better identification of retinal breaks than scleral buckling procedures.

METHODS

A prospective study was performed of primary vitrectomy for the treatment of 25 consecutive cases of pseudophakic and aphakic retinal detachment.

RESULTS

The primary retinal reattachment rate was 84% (21 eyes). Surgical failure resulted from new/missed retinal breaks (2 eyes) and proliferative vitreoretinopathy (2 eyes). The final retinal reattachment rate with further surgery was 96% (24 eyes). There were 7 macula-on detachments which all retained their presenting visual acuity. A visual acuity of 6/18 or better was achieved by 56% of the 18 macula-off detachments. Visualisation of the peripheral retina was impaired in 17 eyes and procedures to improve visualisation were performed in 7 eyes. Retinal breaks were detected in 16 eyes at surgery that had not been identified pre-operatively. Raised intraocular pressure was the most common complication, affecting 10 eyes in the early post-operative period.

CONCLUSIONS

Primary vitrectomy offers certain advantages in the treatment of pseudophakic and aphakic retinal detachments. A controlled study is required to determine whether primary vitrectomy achieves a better outcome than scleral buckling procedures for these retinal detachments.

Vitreoretinal surgery outcomes. Impact on bilateral visual function

PURPOSE

The authors evaluated the impact of vitreoretinal surgery for epiretinal membrane (ERM), rhegmatogenous retinal detachment (RRD), and complex retinal detachment (CRD) on bilateral visual function.

METHODS

Anatomic and visual acuity outcomes were reviewed by the authors for all patients who underwent surgery for ERM, RRD, or CRD during a 2-year period. Several outcome measures of bilateral visual function were applied to quantitate the impact of surgery on bilateral visual function. Data were also analyzed by subdividing patients into two cohorts based on whether vision in the fellow eye was normal (visual acuity > or = 20/40) or abnormal (visual acuity < or = 20/50) at baseline.

RESULTS

Anatomic and visual acuity outcomes of 187 study eyes were similar to previous studies. Postoperatively, the study eye was the eye with better vision in 30.9%, 26.8%, and 16.7% of patients with ERM, RRD, and CRD, respectively. The mean bilateral visual impairment according to American Medical Association Guidelines for Disability decreased postoperatively by 8.7% points, 6.8% points, and 3.6% points, respectively, and decreased most when vision in the fellow eye was abnormal. A higher bilateral visual system functional level resulted postoperatively in 10.7% of all patients, including 28.6% of patients with abnormal vision in the fellow eye (by definition, the visual system functional level of patients with normal vision in the fellow eye could not be improved).

CONCLUSIONS

Surgery was associated with a reduction in bilateral visual disability among patients with ERM, RRD, and CRD, and 28.6% of patients with abnormal vision in the fellow eye achieved a higher bilateral visual functional level.