Vitrectomy and gas for inferior break retinal detachments: are the results comparable to vitrectomy, gas, and scleral buckle?

PRESENTATIONS AND FACTORS AFFECTING OUTCOME OF RHEGMATOGENOUS RETINAL DETACHMENT WITH CHOROIDAL DETACHMENT: An Indo-Taiwanese Study

PURPOSE

To report the clinical settings, management, and factors associated with outcomes of rhegmatogenous retinal detachment with concurrent choroidal detachment.

METHODS

Retrospective, consecutive, multicenter case series from January 2014 to January 2021 were included. Cases were from a tertiary eye care center in India and Taiwan.

RESULTS

Overall 303 eyes were included. Mean age was 43.72 ± 20.64 years (median 46). Best-corrected presenting visual acuity was 1.79 ± 0.92 logMAR (median 2.10) (Snellen 20/1,233). Forty-four patients (17.91%) received preoperative steroids. Final visual acuity was 1.33 ± 0.94 logMAR (median 1.10) (Snellen 20/427). Favorable anatomic outcome was seen in 200/303 (66%), whereas favorable functional outcome was seen in 128/303 (42.20%). Factors predicting favorable anatomic outcome were absence of phakic lens status (odds ratio [OR] 2.76), absence of proliferative vitreoretinopathy worse than Grade A (OR 7.69), use of preoperative steroids (OR 4.50), and use of an encircling band (3.85). Factors predicting favorable functional outcome were better presenting visual acuity (OR 3.03), absence of phakic lens status (OR 4.93), absence of proliferative vitreoretinopathy worse than Grade A (OR 10.41), and use of preoperative steroids (OR 7.24).

CONCLUSION

Administration of preoperative steroids, use of an encircling band during surgery, and pseudophakic status of the eye were found to have better outcomes in rhegmatogenous retinal detachment with concurrent choroidal detachment.

Scleral Buckle, Vitrectomy, or Combined Surgery for Inferior Break Retinal Detachment: Systematic Review and Meta-Analysis

TOPIC

To compare outcomes of scleral buckle (SB), pars plana vitrectomy (PPV), and combined PPV-SB to treat rhegmatogenous retinal detachments (RRDs) with inferior retinal breaks (IRBs).

CLINICAL RELEVANCE

Rhegmatogenous retinal detachments with IRBs are not uncommon; their management is challenging with higher risk of failure. There is no consensus about their treatment, specifically whether SB, PPV, or PPV-SB should be performed.

METHODS

Systematic review and meta-analysis. Randomized controlled trials, case-control, and prospective/retrospective series (if n > 50) in English were eligible. Medline, Embase, and Cochrane databases were searched up to January 23, 2023. Standard systematic review methods were followed. The following outcomes at 3 (± 1) and 12 (± 3) months were evaluated: number of eyes with retinal reattachment after ≥ 1 surgeries, change in best-corrected visual acuity from preoperative to postoperative levels, and number of eyes with improvement of > 10 and > 15 ETDRS letters after surgery. Authors of eligible studies were asked for individual participant data (IPD) and IPD meta-analysis was undertaken. Risk of bias was assessed using National Institutes of Health study quality assessment tools. This study was registered prospectively in PROSPERO (CRD42019145626).

RESULTS

A total of 542 studies were identified: 15 were eligible and included and 60% were retrospective. Individual participant data was obtained from 8 studies (1017 eyes). Given that only 26 patients had received SB alone, these data were not considered in the analysis. There was no evidence for differences between treatment groups (PPV versus PPV-SB) in the probability of having a flat retina at 3 or 12 months postoperatively after 1 (P = 0.067; odds ratio [OR], 0.47; P = 0.408; OR 2.55; respectively) or > 1 (OR, 0.54; P = 0.21; OR, 0.89; P = 0.926; respectively) surgery. Pars plana vitrectomy-SB showed less improvement in vision postoperatively at 3 months (estimate, 0.18; 95% confidence interval, 0.01-0.35; P = 0.044), but this difference was no longer observed at 12 months (estimate, -0.07; 95% confidence interval, -0.27, 0.13; P = 0.479).

CONCLUSION

Available evidence suggests a lack of benefit of adding SB to PPV to treat RRDs with IRBs. Evidence, however, comes mainly from retrospective series and, thus, despite the large number of eyes included, should be interpreted with caution. Further research is needed.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Stratifying the risk of re-detachment: variables associated with outcome of vitrectomy for rhegmatogenous retinal detachment in a large UK cohort study

INTRODUCTION

To identify variables associated with primary anatomical outcome following vitrectomy and internal tamponade for rhegmatogenous retinal detachment (RD).

METHODS

A retrospective analysis of prospectively collected data, using a database of RD treated with vitrectomy and internal tamponade. Collected data complied with the RCOphth Retinal Detachment Dataset. The main outcome measure was anatomical failure within six months of surgery.

RESULTS

There were 6377 vitrectomies. 869 eyes were excluded, either because no outcome was recorded, or inadequate follow up, leaving 5508 operations for analysis. 63.9% of patients were male, and the median age was 62. Primary anatomical failure occurred in 13.9%. On multivariate analysis, the following were associated with increased risk of failure: age <45, or >79, inferior retinal breaks, total detachment, one quadrant or greater inferior detachment, low density silicone oil, and presence of proliferative vitreoretinopathy. C2F6 tamponade, cryotherapy, and 25 G vitrectomy, were associated with reduced risk of failure. The area under the receiver operator curve was 71.7%. According to this model, 54.3% of RD are at low risk (<10%), 35.6% are at moderate risk (10-25%), and 10.1% are at high risk (>25%) of failure.

CONCLUSIONS

Previous attempts to identify high risk RD have been limited by small numbers, the inclusion of both scleral buckling and vitrectomy, or by excluding some types of RD. This study examined outcomes in unselected RD, treated by vitrectomy. Identification of the variables associated with anatomical outcome after RD surgery enables accurate risk stratification, which is valuable for patient counselling and selection, and for future clinical trials.

MINIMAL GAS VITRECTOMY WITH SCLERAL BUCKLE TO MINIMIZE RETINAL DISPLACEMENT IN RHEGMATOGENOUS RETINAL DETACHMENT WITH INFERIOR BREAKS

PURPOSE

To present a novel technique, minimal gas vitrectomy with scleral buckle, as a means of potentially minimizing retinal displacement compared with standard vitrectomy or vitrectomy/scleral buckle for select cases.

METHODS

A patient with right macula-off retinal detachment and retinal breaks at 7 o'clock and 10 o'clock underwent a 23-gauge pars plana vitrectomy, localization, and cryopexy of the breaks along with an inferior temporal segmental scleral buckle. No air-fluid exchange was performed. Suturing of sclerotomies, anterior chamber paracentesis of 0.3 mL, and intravitreal injection of 0.6 mL pure sulfur hexafluoride were then performed. The patient was advised to perform the steamroller maneuver with initial face-down positioning for 6 hours.

RESULTS

The patient achieved retinal reattachment, and postoperative wide-field fundus autofluorescence imaging demonstrated high-integrity retinal attachment with no retinal displacement.

CONCLUSION

The minimal gas vitrectomy with scleral buckle technique has the potential to minimize retinal displacement in cases with inferior break(s) by using a small volume expansile gas tamponade and localized scleral buckle compared with standard vitrectomy or vitrectomy/scleral buckle with a full gas fill.

Air versus Perfluoropropane Gas in Pars Plana Vitrectomy for Primary Rhegmatogenous Retinal Detachment: A 3-Year Retrospective Study

INTRODUCTION

This study aimed to compare anatomical outcomes of air and perfluoropropane gas (C3F8) tamponade in pars plana vitrectomy for the treatment of rhegmatogenous retinal detachment (RRD).

METHODS

In this retrospective study, data were gathered from 578 patients (578 eyes) with RRD. The follow-up records of all 578 patients that underwent primary vitrectomy for RRD with air or C3F8 were examined and analyzed. Surgical outcomes of the two groups were compared.

RESULTS

A total of 342 eyes were treated with air and 236 with C3F8. The mean follow-up period was 37.65 ± 2.33 months. Baseline and preoperative clinical characteristics were similar between groups, but the period to intraocular bubble disappearance (p < 0.0001), intraocular pressure on the first postoperative day (p < 0.0001), number of cases with intraocular pressure >21 mm Hg within 3 days post-surgery (p < 0.0001), and the number with intraocular pressure >21 mm Hg during follow-up (p = 0.0002) differed significantly between groups. Primary reattachment rates for air and C3F8 groups were 95.03% and 95.34%, respectively. Clinical characteristics were similar in those with and without successful reattachment, and the frequency of new or unclosed breaks was similar between the two groups. There was no significant difference in two groups according to the presence or absence of inferior retinal breaks and inferior detached quadrants. Univariate and multivariate logistic regression identified no risk factor for surgical failure.

CONCLUSIONS

Air showed equivalent effects to C3F8, with a shorter period to intraocular bubble disappearance, less risk of postoperative intraocular hypertension, and less expense.

Outcomes of 25-gauge pars plana vitrectomy alone with air tamponade for the management of rhegmatogenous retinal detachment with inferior breaks

Background

This study was investigated the surgical outcomes of primary rhegmatogenous retinal detachment (RRD) with inferior retinal breaks (IRBs) that were repaired by 25-gauge pars plana vitrectomy (PPV) with air tamponade.

Methods

This retrospective review included 81 consecutive patients who had RRD with IRBs and underwent PPV with air tamponade in our hospital from January 2017 to January 2020. The main outcomes were single surgery anatomical success (SSAS) rate, postoperative best-corrected visual acuity (BCVA), and complications.

Results

The patient population consisted of 29 women and 52 men (mean age, 52.12 years); the mean follow-up interval was 8.88 months. The mean number of affected quadrants was 1.65 (range, 1–4 quadrants) and the mean number of breaks was 3.25. A single break was present in 20 cases (24.7%); two to 10 breaks were present in 61 (75.3%) cases. The SSAS rate was 91.36% (74/81) and the final anatomical success rate was 96.30% (78/81). More than half of the patients had BCVA < 0.3 logarithm of the minimum angle of resolution at the last follow-up. Axial length and patient age were candidate risk factors for redetachment (axial length, p = 0.03; age, p = 0.002). Postoperative complications included macular epiretinal membrane formation in one patient, lens opacity in three patients, and clinically significant macular edema in one patient.

Conclusions

PPV with air tamponade may be effective for the treatment of primary RRD with IRBs. Extensive preoperative discussion may be necessary for young patients and patients with particularly long axial length.

Air Tamponade for Rhegmatogenous Retinal Detachment With Inferior Breaks After 25-Gauge Pars Plana Vitrectomy: Technique and Outcome

To evaluate the outcomes of 25-guage (G) pars plana vitrectomy (PPV) with air tamponade for rhegmatogenous retinal detachment (RRD) with inferior breaks. This retrospective consecutive case series included fifty-two eyes of fifty-two RRD patients with inferior breaks who underwent 25-G PPV with air tamponade. These patients were followed up for at least 6 months following surgery. Primary and final anatomical success rates and postoperative complications were the main outcome measures. The mean age of the patients (39 men and 13 women) was 51.8 ± 11.8 years. There were 49 primary RRDs (94.2%) and three recurrent RRDs (5.8%). The mean follow-up period was 8.2 ± 1.6 months (range: 6–13 months). Sixteen eyes (30.8%) presented with high myopia, and six eyes (11.5%) were pseudophakic. Proliferative vitreous retinopathy grade was C1 in four eyes (7.7%). Of the 52 eyes, two (3.8%) were complicated with choroidal detachment, and forty (76.9%) had the macula detached. The single- and final-operation success rates were 96.2% and 100%, respectively. During follow-up, secondary cataract surgery was performed in eight eyes (17.4%) of the 46 phakic eyes. 25-G PPV with air tamponade is effective in treating selected RRD patients with inferior breaks. Patients can benefit from early visual recovery and less complications.

Influence of the scleral indentation technique on the re-detachment rate following retinal detachment surgery

Purpose

The aim of this study was to determine whether the choice of scleral indentation technique during primary rhegmatogenous retinal detachment surgery has an influence on the risk of re-detachment.

Methods

We included retrospectively 154 eyes with a primary rhegmatogenous retinal detachment treated in the Eye Clinic Sulzbach/Saar Germany, who were operated on by two experienced surgeons using the same basic surgical setup. Surgeon A performed an external 360° indentation, shaved the vitreous base using the light pipe cap, and used the operating microscope (opm) for direct visualization. Surgeon B performed an external 360° indentation, shaved the vitreous base using a simple indentor, and used an endoillumination (light pipe) with the opm and a handheld widefield lens for direct visualization.

Results

Comparing both indentation procedures, 15.66% (13/83) of patients operated on by surgeon A and 9.86% (7/71) of patients operated on by surgeon B had a retinal re-detachment within a follow-up period of 6 months (adj. p = 0.64, two-proportion Z-test).

Conclusion

The rate of retinal re-detachment could be influenced by the indentation technique at the end of surgery favoring external indentation and internal visualization with an endoilluminator (chandelier light). We attribute this to the better visualization of the vitreous base facilitated by endoillumination. However, many variables play a role in the development of retinal re-detachment, requiring further studies with a larger number of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-022-00362-8.

What we already know:

Scleral indentation is widely recognized as an important step in rhegmatogenous retinal detachment surgery via pars-plana vitrectomy.

There are several surgical techniques for scleral indentation, however the procedures are neither standardized, nor have they ever been compared to one another to the best of our knowledge.

What this study adds:

This study shows that the rate of retinal re-detachment could be influenced by the indentation technique at the end of surgery favoring external indentation and internal visualization with an endoilluminator (chandelier light).

We attribute this to the better visualization of the vitreous base facilitated by endoillumination.

Scleral Buckling: A Review of Clinical Aspects and Current Concepts

Scleral buckling represents a valuable treatment option for rhegmatogenous retinal detachment repair. The surgery is based on two main principles: the closure of retinal breaks and the creation of a long-lasting chorioretinal adhesion. Buckles are placed onto the sclera with the purpose of sealing retinal breaks. Cryopexy is usually performed to ensure a long-lasting chorioretinal adhesion. Clinical outcomes of scleral buckling have been shown to be more favorable in phakic eyes with uncomplicated or medium complexity retinal detachment, yielding better anatomical and functional results compared with vitrectomy. Several complications have been described following scleral buckling surgery, some of which are sight-threatening. Expertise in indirect ophthalmoscopy is required to perform this type of surgery. A great experience is necessary to prevent complications and to deal with them. The use of scleral buckling surgery has declined over the years due to increasing interest in vitrectomy. Lack of confidence in indirect ophthalmoscopy and difficulties in teaching this surgery have contributed to limiting its diffusion among young ophthalmologists. The aim of this review is to provide a comprehensive guide on technical and clinical aspects of scleral buckling, focusing also on complications and their management.

Efficiency benchmarks in the surgical management of primary rhegmatogenous retinal detachment: a monocentric register cohort study of operating room time metrics and influential factors

OBJECTIVES

To investigate the effect of clinical, methodological and logistic factors on operating room (OR) efficiency in the surgical management of primary rhegmatogenous retinal detachment (RRD).

DESIGN

Monocentric retrospective register cohort study.

SETTING

Single tertiary centre in the western region of Austria.

PARTICIPANTS

We audited patients diagnosed with primary RRD who were treated between January 2014 and August 2019. In total, 783 eyes of 776 consecutive patients were included in this study. Various risk factors affecting OR time efficiency and anatomical success after pars plana vitrectomy (PPV) procedures and scleral buckle (SB) surgery were analysed.

PRIMARY AND SECONDARY OUTCOME MEASURES

OR efficiency was the primary outcome measure. Secondary outcome measures were the primary success rate after PPV procedures and SB surgery.

RESULTS

PPV was performed in 641 (81.9%) eyes and SB surgery in 142 (18.1%) eyes. Mean surgical times in PPV and SB under retrobulbar anaesthesia (RA) were 74.0 (±32.6) min and 62.1 (±24.6) min (p<0.001), respectively, while under general anaesthesia (GA), these values were 112.0 (±52.0) min and 76.0 (±22.5) min (p<0.001), respectively. A regression analysis revealed the following main risk factors for prolonged OR time for the surgical management of RRD with PPV (all p<0.001): presence of a giant tear (β=24.01; 32%), proliferative vitreoretinopathy (PVR)-C (β=16.43; 22%), surgery postponed for 72 hours after diagnosis (β=21.40; 29%), GA (β=23.64; 32%) or surgery performed by a trainee (β=17.35; 23%). PVR (p=0.022) in PPV cases, after-hours settings (p=0.006) and surgeon experience (p=0.030) in SB cases were independent risk factors for reduced success rates.

CONCLUSIONS

OR coordinators should consider various independent clinical (giant tear, PVR-C, advanced detachment), methodological (PPV vs SB) and logistic (GA vs RA, after-hours setting and surgeon experience) factors to improve the success rate and surgical management planning of RRD accurately while optimising OR resources and staff efficiency.

PATCHING RETINAL BREAKS WITH HEALAFLOW IN 27-GAUGE VITRECTOMY FOR THE TREATMENT OF RHEGMATOGENOUS RETINAL DETACHMENT

Supplemental Digital Content is Available in the Text.

This study evaluates the effectiveness of Healaflow as a retinal patch in primary rhegmatogenous retinal detachment repaired by 27-G pars plana vitrectomy combined with air tamponade. This protocol results in a high reattachment rate in the treatment of rhegmatogenous retinal detachment.

Purpose:

To report the surgical outcomes of primary rhegmatogenous retinal detachment (RRD) repaired by 27-gauge pars plana vitrectomy combined with Healaflow patch and air tamponade.

Methods:

In an initial vitro experiment, we observed and compared the dissolution and displacement of the dispersion spots of 0.05-mL Healaflow and sodium hyaluronate. We then performed a prospective, interventional cohort study on 38 eyes in 37 consecutive patients with primary rhegmatogenous retinal detachment. All eyes underwent pars plana vitrectomy combined with Healaflow patch and air tamponade; the postoperative period did not involve prone positioning. The primary and final anatomical attachment rate, best-corrected visual acuity, and intraoperative and postoperative complications were evaluated.

Results:

In the in vitro experiment, the viscoelastic Healaflow remained adherent with no change in the size of the area; however, the control dissolved completely in the balance solution. The patient study included 16 women (43.2%) and 21 men (56.8%) (mean age, 59.5 ± 9.5 years; mean follow-up period, 8.9 ± 3.8 months). A single break was present in 21 (55.3%) and 2 to 5 breaks in 17 cases (44.8%). The macula was involved in 25 (65.8%) and attached in 13 cases (34.2%) intraoperatively. Initial reattachment was achieved in 37 (97.4%) and final reattachment in 38 cases (100%). In one case (2.6%), the macula redetached because of failure of the chorioretinal scar to develop around the treated break. Mean preoperative and postoperative best-corrected visual acuities were 1.02 ± 0.82 logarithm of the minimum angle of resolution (median Snellen acuity: 20/125, range: 20/20,000–20/20) and 0.23 ± 0.17 logarithm of the minimum angle of resolution (median Snellen acuity: 20/32, range: 20/100–20/20), respectively (P < 0.001). Intraocular pressure was elevated transiently in 28 eyes (73.7%). There were no other intraoperative complications or postoperative scleral incision leakage.

Conclusion:

A 27-gauge pars plana vitrectomy combined with Healaflow patch, and air tamponade results in a high reattachment rate in the treatment of rhegmatogenous retinal detachment. Thus, patients can benefit from early visual recovery and less complications.

Combined Pars Plana Vitrectomy and Segmental Scleral Buckle for Rhegmatogenous Retinal Detachment with Inferior Retinal Breaks

Purpose

To describe a variation of the traditional segmental scleral buckle (SB) without an encircling band combined with 23-gauge pars plana vitrectomy (PPV) for the management of rhegmatogenous retinal detachment (RRD) with inferior retinal breaks.

Patients and Methods

This is a single-center, retrospective, consecutive review of all RRDs with inferior retinal breaks that were treated with PPV and segmental SB without an encircling band between May 2019 and February 2020.

Results

A total of 12 eyes of 12 patients were included in the study. All patients had at least 1 inferior retinal break and more than 2 clock hours of retinal detachment. Eight eyes had RRD with macular involvement at presentation. Seven eyes had a persistent RRD following previous pneumatic retinopexy (C3F8). All eyes were treated by PPV combined with a segmental #510 sponge without an encircling band. Surgery anatomical success was 100%. Mean logMAR visual acuity was 1 (SD 0.6; 20/160) and 0.5 (SD 0.4; 20/60) at 3 months and last follow-ups, respectively. No scleral buckle-related complications were noted over the 4.1 (SD 0.8) month follow-up period.

Conclusion

The combined segmental buckling technique is a safe and effective adjunct to PPV in treatment of inferior RRD.

The Effectiveness of the Supine Position in Managing Inferior Breaks in Rhegmatogenous Retinal Detachment After Vitrectomy with Gas Tamponade

Objective

This study aims to determine whether the supine position is effective for the management of inferior peripheral breaks after pars plana vitrectomy with gas tamponade.

Methods

A total of 29 patients (29 eyes) with acute rhegmatogenous retinal detachment and causative peripheral inferior breaks, located between the four o’clock and eight o’clock positions, underwent pars plana vitrectomy with gas tamponade. These patients maintained a face-up supine position for at least six hours each day for 14 days postoperatively. The alternate lateral position was used for the remaining hours, depending on the distribution of the retinal breaks.

Results

The final retinal reattachment rate was 100%, and the visual acuity improvement rate was 100% postoperatively, with no recurrence during the one-year follow up. No patients suffered from any sight-threatening complications. Of the 16 patients with preoperatively clear lenses, 3 were documented to have a cataract during their three-month postoperative follow up. Four patients were documented to have increased intraocular pressure, which was controllable during the early postoperative days.

Conclusion

Postoperative pars plana vitrectomy and gas tamponade in the supine position is effective for managing primary rhegmatogenous retinal detachment with causative breaks between the four o’clock and eight o’clock positions.

APPLICATION OF MODIFIED NEI VFQ-25 AFTER RETINAL DETACHMENT TO VISION-RELATED QUALITY OF LIFE

PURPOSE

We examined the postoperative visual recovery and quality of life after retinal detachment (RD) surgery.

METHODS

In addition to a baseline clinical examination, patients filled out the National Eye Institute Visual Functioning Questionnaire at three time points: preoperatively and 1 and 3 months postoperatively (M1 and M3, respectively). We analyzed the composite score and short-form scores (socioemotional scale [SFSES] and visual functioning scale [SFVFS]).

RESULTS

One hundred ninety-four patients were enrolled in this study; 47 (26 macula-ON RD and 21 macula-OFF RD) returned all three questionnaires. The best corrected visual acuity was Snellen equivalent 20/25, 20/25, and 20/20 at the preoperative, M1, and M3 assessment, respectively. At M3, we found a positive correlation between SFSES and best corrected visual acuity measures among macula-OFF patients (P < 0.001, R2 = 0.58). A significant correlation with the best corrected visual acuity among macula-ON patients was observed only at M3 with the SFVFS score (P < 0.001, R2 = 0.41).

CONCLUSION

The quality of life differs between ON and OFF RD in regard to the composite score and especially SFSES and SFVFS. We found a transient decrease in the quality of life at M1 for macula-ON patients, whereas the quality of life improved throughout follow-up among macula-OFF patients. These data may help improve the management of patients' expectations after RD surgery.

Incidence of Clinically Significant Aniseikonia Following Encircling Scleral Buckle Surgery: An Evaluation of Refractive and Axial Length Changes Requiring Intervention

To evaluate the incidence of symptomatic anisometropia and aniseikonia requiring intervention following surgery with combined pars plana vitrectomy (PPV) and broad 276 style encircling scleral buckle (ESB) for the repair of rhegmatogenous retinal detachments (RRD) and to report axial length (AL) and keratometry changes, a retrospective review of consecutive RRD patients treated with combined PPV and ESB between June 2016 until September 2019 was performed. All patients with symptomatic optically induced aniseikonia requiring additional interventions or surgical procedures including clear lens exchanges, secondary intraocular lens implants or contact lenses were documented. Keratometry and AL measurements were recorded for each eye and changes calculated. In total, 100 patients underwent combined PPV, ESB and endotamponade with mean age of 59.47 years (SD 11.49). AL was significantly increased (25.39 mm [SD 1.27] to 26.54 mm [SD 1.16], p = 0.0001), with a mean change of 1.15 mm (SD 0.67). Mean corneal astigmatism increased by –0.95 D (SD 0.51) in control eyes preoperatively and –1.33 (SD 0.87) postoperatively (p = 0.03). Over half of phakic patients (39/61; 64%) developed a visually significant cataract, subsequently undergoing surgery. Six of 100 patients developed symptomatic anisometropia with aniseikonia postoperatively (6%). Four proceeded with clear lens exchange despite absence of visually significant cataract (4%). Two of these initially trialled contact lenses (2%). One was intolerant, while the other decided to proceed with clear lens exchange for convenience. Only one patient (1%), being pseudophakic in both eyes, had persistent anisometropia/aniseikonia. AL and keratometry changes induced by encirclement with broad solid silicone rubber buckles are acceptable and similar to those reported previously using narrow encircling components, being unlikely to induce troublesome symptomatic anisometropia/aniseikonia. Many patients are phakic and develop visually significant cataracts, allowing correction of changes induced with the aim of visual restoration. A minority require more prolonged methods of visual rehabilitation, such as contact lens wear or clear lens exchanges. Caution and appropriate consent should be made in patients that are pseudophakic in both eyes at presentation.

Results of different strategies to manage complicated retinal re-detachment

PURPOSE

Complicated retinal re-detachment with inferior proliferative vitreoretinopathy (PVR) remains a challenge. This study's aim was to compare vitrectomy with conventional silicon oil (CSO) combined with an encircling band (EB) and vitrectomy with heavy silicon oil (HSO) alone to treat retinal re-detachment through inferior PVR, where standard procedures have already failed.

METHODS

A retrospective analysis was done on patients with inferior complex re-detachment with secondary PVR after primary surgery, who received pars plana vitrectomy (PPV) with CSO combined with EB (group 1) or PPV alone with HSO (group 2) between December 2006 and August 2017. The primary endpoint was retinal reattachment, and the secondary endpoint was visual acuity (VA) change and complications in both groups.

RESULTS

This study included 119 eyes. Total single surgery anatomical success (SSAS) was 64%, with 80% (52/65) achieved in group 1 and 44.5% (24/54) in group 2 (p < 0.0001). The total final anatomical success (FAS) rate was 79% (94/119). In group 1, FAS was 91% (59/65) compared with 65% (35/54) in group 2 (p = 0.003). The pretreatment VA of group 1 had a median of 1.4 logMAR (95% CI 0.3-1.8), and group 2 showed a median of 1.4 logMAR (95% CI 0.2-1.8). The post-treatment decrease in group 1 was a median equal to - 0.6 versus - 0.1 for group 2 (p = 0.0001). Serious complications were similar in both groups.

CONCLUSION

For complicated retinal re-detachment through inferior PVR, the combination of PPV with EB may lead to better anatomical (SSAS, FAS) and functional success compared with PPV alone with HSO.

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.

Preoperative Optical Coherence Tomography Findings of Foveal-Splitting Rhegmatogenous Retinal Detachment

PURPOSE

To assess preoperative optical coherence tomography (OCT) findings of foveal-splitting retinal detachment (RD) and determine postoperative outcomes.

METHODS

Consecutive patients who underwent RD surgery over a 1-year period were included. Patients diagnosed with a detachment extending to the edge of the fovea on fundus examination (i.e., macula-On/Off) underwent macular OCT scanning. Visual acuity (VA) after 1 year of macula-On/Off, macula-On, and macula-Off eyes was compared.

RESULTS

A total of 85 eyes were included, 8 of which had a macula-On/Off RD. On preoperative OCT, all macula-On/Off RD eyes had foveal detachment extending beyond the foveal center over a median distance of 632 µm. Mean VA of the macula-On/Off eyes had improved from 20/160 to 20/40 at 1 year postoperatively (p = 0.035). The preoperative VA of macula-On/Off eyes was significantly better than macula-Off eyes (p = 0.032) and lower than macula-On eyes (p = 0.004). At 1 year, the VA of macula-On/Off eyes was no different from that of the macula-On eyes (p = 0.320), and tended to be better than that of the macula-Off eyes (p = 0.062).

CONCLUSION

Preoperative OCT revealed a shallow RD extending beyond the foveal center in eyes with clinical foveal-splitting RD. These eyes, termed macula-On/Off RD eyes, had a preoperative VA between macula-On and macula-Off eyes, while their final VA was close to those with macula-On RD.

Internal limiting membrane peel: Does it change the success rate of primary vitrectomy without belt buckle in rhegmatogenous retinal detachments?

Purpose:

To compare the anatomic success of pars plana vitrectomy (PPV) after internal limiting membrane (ILM) peeling at macular area and macular plus peripapillary area versus no peeling in rhegmatogenous retinal detachments (RRD).

Methods:

A prospective observational study between July 2014 and March 2017 conducted on 289 eyes of 287 patients with RRD were randomly assigned to three treatment procedures, viz., PPV with no ILM peeling, PPV with macular peeling, and PPV with macular plus peripapillary peeling. Recurrent RD (ReRD) was treated as an event and accordingly the overall primary (PS) and final success (FS) rates were obtained. The risk of ReRD associated with peeling procedures after adjusting for risk factors were obtained using Cox-proportional hazard analysis.

Results:

The PS percentage for no peel, macular, and macular plus peripapillary procedures were 77.78% (70/90), 82.18% (83/101), and 94.89% (93/98; maximum), respectively, which was statistically significant with a P value of 0.003. The FS percentage for no peel, macular, and macular plus peripapillary were 93.33%, 95.04%, and 100%, respectively, which was significantly different with a P value of 0.048. With reference to no peeling, the adjusted hazard ratio for macular peeling was 0.841 [95% CI: 0.44–1.60] while 0.235 [95% CI: 0.088–0.626] for macular plus peripapillary peeling.

Conclusion:

The anatomic success rate of PPV with macular plus peripapillary ILM peeling was significantly higher as compared to no peel category. The hazard of ReRD in patients undergoing macular plus peripapillary peel was significantly reduced as compared to no peel procedure.

SEQUENTIAL PNEUMATIC RETINOPEXIES FOR THE TREATMENT OF PRIMARY INFERIOR RHEGMATOGENOUS RETINAL DETACHMENTS WITH INFERIOR BREAKS: The Double-Bubble Approach

PURPOSE

To evaluate a new approach of sequential pneumatic retinopexies for the management of inferior rhegmatogenous retinal detachments (RD) with inferior breaks.

METHODS

Multicenter retrospective consecutive case series of inferior RDs caused by retinal breaks located within the inferior 4 clock hours treated with sequential pneumatic retinopexies, 24 to 48 hours apart. A total of 26 patients with inferior RDs secondary to one or more breaks between the 4 o'clock and 8 o'clock meridians were included from September 2007 to February 2012.

RESULTS

The mean follow-up duration was 35.3 weeks. Anatomical success at 8 weeks was achieved in 65.4% of all patients (including those with giant retinal tear and patients with previous RD in the study eye). When excluding patients with giant retinal tear and previous RD in the study eye, the anatomical success rate increased to 70%. Overall, the mean visual acuity improved from 1.00 logMAR (Snellen equivalent 20/200) at baseline to 0.38 logMAR (Snellen equivalent 20/50) at last follow-up.

CONCLUSION

Sequential pneumatic retinopexy offers a new viable surgical option for the treatment of RDs secondary to inferior breaks.

The comparison of the surgical outcome of 27-gauge pars plana vitrectomy for primary rhegmatogenous retinal detachment between air and SF6 gas tamponade

OBJECTIVES

To compare the surgical results between air and 20% sulfur hexafluoride (SF6) tamponade in 27-gauge pars plana vitrectomy (27GPPV) for rhegmatogenous retinal detachment (RRD).

METHODS

A retrospective, observational, and consecutive study. All patients underwent 27GPPV for RRD were divided into two groups. Group A comprised patients who underwent 20% SF6 gas tamponade. Group B comprised patients who underwent air tamponade. The anatomical success rate, visual outcome, and the type and frequency of complications were investigated and compared between the groups. All patients were followed-up for 12 months after surgery.

RESULTS

Seventy eyes were enrolled (Group A: 35 eyes, Group B: 35 eyes). Seventeen eyes in Group A and 13 eyes in Group B had RRD with superior retinal breaks, while 14 eyes in Group A and 19 eyes in Group B had RRD with inferior retinal breaks. There was no statistically difference in preoperative demographic date between the groups. The initial and final anatomical success rates were 97.1% and 100% in Group A and 94.3% and 100% in Group B, respectively. The success rates between the groups were not statistically different (p = 1). The best corrected visual acuity (BCVA) (logMAR) at 12 months after surgery was -0.02 ± 0.14 in Group A and -0.03 ± 0.27 in Group B. The BCVA between the groups was not statistically different (p = 0.27).

CONCLUSIONS

The surgical results of air tamponade were not inferior to 20% SF6 tamponade in 27GPPV for RRD irrespective of retinal break locations in the present cohort.

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.

Vitrectomy with and without encircling band for pseudophakic retinal detachment with inferior breaks: VIPER Study Report No. 3

Purpose

To test if an encircling band improves outcomes in vitrectomy for pseudophakic retinal detachment (PRD) with inferior or with multiple (4 or more) breaks.

Methods

Subgroup analysis of a prospective randomized controlled multicenter trial in patients with uncomplicated PRD assigned either to 20 G vitrectomy plus encircling band (group E1), or 20 G vitrectomy without any buckle (group C), or 23/25 G vitrectomy without any buckle (group E2). The primary endpoint was defined as no indication for any retina reattaching procedure during the review period of 6 months. One hundred out of 257 patients were identified with inferior breaks and 63 patients had 4 or more breaks.

Results

In patients with retinal breaks between 5:00 and 7:00, treatment was successful in 77.4% (24/31, treatment arm E1) versus 57.1% (16/28, treatment arm C) (p = 0.301, odds ratio (OR) 1.83, 95% confidence interval (CI) 0.48 to 7.17). In patients with multiple breaks, success rates were 68.2% (15/22, E1) versus. 72.4% (21/29, C, p = 0.46, OR 0.52, CI 0.08–3.65).

Conclusion

Combining an encircling band with vitrectomy in patients with pseudophakic retinal detachment and inferior or multiple breaks does not significantly improve primary anatomical success in comparison to treatment with 20 G or 23/25 G vitrectomy alone.

Vitrectomy without prone positioning for rhegmatogenous retinal detachments in eyes with inferior retinal breaks

Purpose

To compare the anatomic and functional outcomes of pars plana vitrectomy (PPV) for treating rhegmatogenous retinal detachments (RRDs) between two groups with and without postoperative prone positioning.

Methods

This retrospective cohort study included 142 eyes of 142 patients with a primary RRD. All patients underwent PPV with 20% sulfur hexafluoride gas tamponade and were divided into two groups: the groups that did and did not maintain a prone position postoperatively. All patients were followed for more than 3 months. The main outcome measures were the best-corrected visual acuity (BCVA), retinal reattachment rate, and postoperative complications.

Results

Sixty-five eyes were included in the prone position group and 77 eyes in the group without prone positioning; the respective initial reattachment rates were 83.1% and 96.1%, a difference that reach significance (p = 0.011). In the eyes with inferior breaks, the initial reattachment rate was 94.7% (18 eyes) without prone positioning, which was significantly (p = 0.036) better than the 60% (6 eyes) initial reattachment rate in the group with prone positioning. In the eyes without inferior breaks, there was no significant difference in the initial reattachment rates between the two groups. The BCVAs at the 3-month postoperative visit did not differ significantly between the two groups. An epiretinal membrane (ERM) was observed postoperatively in 10 (13.0%) eyes in the group without prone positioning; no ERMs were seen postoperatively in eyes in which the internal limiting membrane (ILM) was peeled during PPV.

Conclusions

PPV without postoperative prone positioning is associated with a higher reattachment rate in eyes with a RRD, especially those with inferior retinal breaks. PPV with postoperative supine and lateral positioning might be beneficial to manage RRDs associated with inferior retinal breaks if ILM peeling is performed intraoperatively.

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.

Prognostic Factors after Primary Vitrectomy and Perfluorocarbon Liquids for Bullous Rhegmatogenous Retinal Detachment

Purpose

To identify prognostic factors for visual acuity and anatomic outcomes associated with bullous rhegmatogenous retinal detachment (RRD) management using primary pars plana vitrectomy, intraoperative perfluorocarbon liquids (PFCLs), and internal gas tamponade.

Methods

The authors studied a consecutive series of 115 eyes (115 patients) with a bullous RRD not complicated by proliferative vitreoretinopathy (PVR) associated with large, multiple, and/or posterior breaks in 58 (50.4%) eyes. All eyes underwent vitrectomy, injection of PFCL, and gas tamponade as the primary procedure. Encircling scleral bands were placed in all cases. The follow-up period ranged from 3 to 60 months (mean 16.6±14.1 months).

Results

Retinal reattachment was achieved in 92.2% of eyes (106/115) with one operation and in all eyes after a second procedure. PVR was observed in 1 (0.87%) eye and pre-retinal membranes in 3 (2.6%) eyes. Progression of pre-existing cataract and development of new cataract occurred in 45 (58.4%) of the 77 phakic eyes. The presence of inferior retinal breaks was significantly associated with redetachment after the first procedure (p=0.0156). On univariate analysis, better preoperative visual acuity (p<0.001), macular sparing retinal detachment (p<0.001), and fewer quadrants involved by the detachment (p=0.0015) were significant positive prognostic factors for final visual acuity. Logistic regression analysis highlighted that macular sparing retinal detachment and absence of trauma were associated with better final visual acuity.

Conclusions

Redetachment was associated with the presence of inferior retinal breaks. Visual recovery was dependent on preoperative visual acuity, macular involvement, extent of retinal detachment, and trauma.

Silicone oil versus gas tamponade for giant retinal tear-associated fovea-sparing retinal detachment: a comparison of outcome

PurposeSilicone oil is the most common choice of tamponade agent used when managing a giant retinal tear (GRT). Concern exists regarding its potential detrimental effect on vision. We herein report on visual and surgical outcomes of all patients treated at Moorfields Eye Hospital for a GRT over a five year period. We further analysed a subgroup of fovea-sparing retinal detachments (RD) treated by pars plana vitrectomy (PPV) with either silicone oil or gas tamponade.MethodsRetrospective comparative, non-randomised, cross-sectional review of patients with a new diagnosis of GRT from 1 September 2005 to 31 August 2010ResultsOne hundred twenty four eyes of 118 patients were identified with mean age of 45.5 years and median follow-up of 24 months. Subgroup analysis of fovea-sparing RDs (Silicone Oil n=49, Gas n=15) revealed visual loss (≥2 Snellen Lines of vision) in 49.0% (n=24) of patients managed with oil compared to 13.3% (n=2) of gas patients (P=0.019). In all, 73.3% (n=11) in the gas group achieved a final vision of 6/12 or better, compared to 36.7% (n=18) in the oil group (P=0.031). No difference was observed in eventual or primary anatomical success rate (100 vs 93.9%, and 66.7 vs 79.6%, gas vs oil, respectively, (P>0.1)). Postoperative complications were absent in 66.7% (n=10) of gas patients compared with 14.3% (n=7) of oil patients (P=0.002). Multiple variable linear regression determined tamponade choice as the only variable predictive of final visual acuity (P=0.046).ConclusionEyes with fovea-sparing GRT-related RDs managed with gas achieved a better visual outcome with fewer postoperative complications and no significant difference in anatomical success. A multicentre approach to investigate this further is advised.

Anatomical and Functional Results Following 23-Gauge Primary Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment: Superior versus Inferior Breaks

PURPOSE

In this retrospective study, we evaluated the anatomical and functional outcomes of patients with rhegmatogenous retinal detachment primarily treated with pars plana vitrectomy in regard to the location of the breaks. Methods. 160 eyes were enrolled in this study, divided into two groups based on break location: the superior break group (115 eyes) and the inferior break group (45 eyes). The main endpoint of our study was the anatomical success at 3 months following surgery.

RESULTS

Primary retinal reattachment was achieved in 96.5% of patients in group A and in 93.3% in group B (no statistically significant difference, OR 1.98, 95% CI: 0.4, 7.7). Mean BCVA change and intraoperative complication rate were also not statistically significantly different between the two groups (p > 0.05, OR: 1.0, 95% CI: 0.9, 1.01, resp.). Statistical analyses showed that macula status, age, and preoperative BCVA had a significant effect on mean BCVA change (p = 0.0001, p = 0.005, and p = 0.001, resp.).

CONCLUSION

This study supports that acceptable reattachment rates can be achieved using PPV for uncomplicated RRD irrespective of the breaks location and inferior breaks do not constitute an independent risk factor for worse anatomical or functional outcome.

Primary rhegmatogenous retinal detachment - surgical methods and anatomical outcome

PURPOSE

The aim of the study was to evaluate the anatomical success of surgical management of primary rhegmatogenous retinal detachment (RRD) and to compare the anatomical outcomes from different surgical techniques.

METHODS

During 2012, 517 consecutive eyes (514 patients) were operated by 11 surgeons at the Department of Ophthalmology, Oslo University Hospital. Patient records were retrospectively analysed with no exclusions. Main outcome measures were primary and final anatomical success. Primary anatomical success was defined as retinal reattachment 6 months after primary surgery with reoperations excluded. Final anatomical success was defined as retinal reattachment 6 months after primary surgery with reoperations included.

RESULTS

Incidence of RRD was 18.6 eyes per 100 000 person-years. The macula was detached in 50.5% of the eyes at baseline. Of 517 operated eyes, 317 (61.3%) underwent pars plana vitrectomy (PPV), 23 (4.5%) pars plana vitrectomy together with a scleral buckle (PPV-SB), 175 (33.9%) scleral buckle (SB) surgery and two (0.4%) pneumatic retinopexy (PR). Primary anatomical success was 89.0% in the PPV group, 87.0% in the PPV-SB group and 85.7% in the SB group. Final anatomical success was 98.1% in the PPV group, 100% in the PPV-SB group and 99.4% in the SB group. Factors which were correlated to the redetachment were detachment of more than 6 clock hours (p = 0.003) and visual acuity (VA) on Snellen chart <0.5 (p = 0.02) at baseline.

CONCLUSION

This study showed no significant differences in the surgical success rates in the treatment of RRD between pars plana vitrectomy, scleral buckle or the combined procedure of vitrectomy and buckle. Factors which were found to be correlated to the redetachment of the retina were large detachment and low VA.

Vitrectomy with and without encircling band for pseudophakic retinal detachment: VIPER Study Report No 2-main results

Background

It is unclear whether or not an additional encircling band improves outcome in vitrectomy for pseudophakic retinal detachment (PRD). Also unclear is whether small gauge transconjunctival trocar-guided vitrectomy is as successful as conventional 20 gauge (G) vitrectomy.

Methods

257 adult patients with uncomplicated PRD were enrolled in 14 vitreoretinal centres across Germany. Contingent on availability of qualified surgeons, eligible patients were randomly assigned either (i) with ratio 1:1 to 20 G vitrectomy plus encircling band (group E1) or 20 G vitrectomy without any buckle (group C) or (ii) with ratios 1:1:1 to group E1, C or 23/25 G vitrectomy without any buckle (group E2). Treatment success was defined as no indication for any retina reattaching procedure during the follow-up of 6 months.

Results

Success was reached in 79.0% (=79/100, group E1) versus 73.5% (=72/98, group C) (p=0.558, OR 1.32, 95% CI 0.65 to 2.65. In group E2 87.7% (=50/57) of patients reached success compared with 78.7% (=48/61) in group C, demonstrating non-inferiority of E2 to C regarding the prespecified margin of 0.8 (OR scale; p=0.05, OR 2.17, 95% CI 0.80 to 5.89). Best corrected visual acuity significantly increased after surgery independent of technique, that is, on average −0.7 (from 1.0 to 0.3) logMAR. Patients suffered from a shift in spherical refraction of −1.0 D in group E1 compared with −0.1 D in group C. Similarly, intraoperative complications (15.2% vs 8.8% of patients) and serious adverse events (30.3% vs 22.5% of patients) were more frequent in group E1.

Conclusions

Vitrectomy with gas is an efficient and safe treatment for uncomplicated PRD. An additional encircling band does not significantly reduce the risk for any second procedure necessary to reattach the retina in 20 G vitrectomy. Small gauge transconjunctival vitrectomy is not inferior to the conventional 20 G technique.

Trial registration number

DKRS 00003158, Results.

Long-term follow-up of vitrectomy, with or without 360° encircling buckle, for rhegmatogenous retinal detachment due to inferior retinal breaks

Objective

The aim of this study was to report and compare the anatomic and functional results of primary vitrectomy with and without 360° encircling scleral buckle (SB) for the treatment of rhegmatogenous retinal detachment (RRD) due to inferior retinal break(s).

Background

A variety of options, including SB, pars plana vitrectomy (PPV) with or without SB, and pneumatic retinopexy have been described as methods to repair RRDs. The use of additional SB with vitrectomy for RRD associated with inferior breaks has been a recent controversy after the introduction of transconjunctival cannula systems.

Patients and methods

A retrospective, interventional, comparative case study was performed. In this study, we reviewed 105 consecutive patients who underwent vitrectomy for primary RRD with inferior retinal break(s) at the vitreoretinal center, performed by a single surgeon. Ninety four patients (94 eyes) were followed up for at least 4 months after silicon oil removal (SOR), and were analyzed. They were divided into two groups: group I included 50 patients who underwent PPV alone + silicon oil (SO); and group II included 44 patients who underwent PPV with 360° SB + SO. The essential parameters were single-operation success rate (SOSR) before SOR, incidence of retinal redetachment after SOR, and final visual acuity.

Results

SOSR was obtained in 89 eyes (47 [94%] in group I and 42 [95.5%] in group II). From overall 59 phakic retinal detachments (RDs), SOSR was obtained in 56 eyes (30 in group I [93.8%] and 26 in group II [96.3%]) while from overall 35 aphakic or pseudophakic RDs, SOSR was obtained in 33 eyes (17 in group I [94.4%] and 16 in group II [94.1%]). Retinal redetachments after SOR occurred in three patients in group I and two patients in group II. Visual acuity improvement was greater in group I than in group II before SOR.

Conclusion

Both surgical procedures had similar reattachment rates. The addition of 360° SB to PPV + SO might not have additional benefits in patients with RD due to inferior retinal break.

Pars Plana Vitrectomy Alone for the Management of Pseudophakic Rhegmatogenous Retinal Detachment with Only Inferior Breaks

PURPOSE

To report the surgical results of primary pseudophakic rhegmatogenous retinal detachment (RRD) with only inferior retinal breaks (IRBs) repaired by pars plana vitrectomy (PPV) alone and complete drainage of subretinal fluid.

DESIGN

Prospective, interventional cohort study.

PARTICIPANTS

A total of 147 consecutive pseudophakic eyes of 147 patients with primary RRD with causative inferior breaks.

METHODS

All eyes underwent PPV alone and complete drainage of subretinal fluid, with air, 20% sulfur hexafluoride (SF6), or 12% perfluoropropane (C3F8) as tamponade and with no face-down position in the postoperative period.

MAIN OUTCOME MEASURES

Postoperative primary and final anatomic outcome, visual acuity, and complications.

RESULTS

The patient population consisted of 44 women (30%) and 103 men (70%) with a mean age of 60.8±12.9 years. The mean follow-up period was 24.9±19.4 months. The mean number of quadrants affected was 2.4 (range, 1-4). A single break was present in 90 cases (61.2%), and 2 to 4 breaks were present in 57 cases (38.8%). The macula was found to be detached in 118 cases (80.3%) and attached in 29 cases (19.7%) intraoperatively. Of 152 breaks located between 5 and 7 clock-hours, 124 breaks (81.6%) were located outside the limits of the gas bubble on the first or third day postoperatively. Initial reattachment was achieved in 139 cases (94.5%; 95% confidence interval, 89.5-97.6). Final reattachment was achieved in 147 cases (100%). Two cases (1.3%) redetached because of new or missed retinal breaks. Six cases (4.1%) redetached because of incomplete retinal adhesion of the treated break(s). Mean preoperative best-corrected visual acuity (BCVA) was 1.11±0.59 logarithm of the minimum angle of resolution (logMAR). The mean final postoperative BCVA was 0.42±0.33 logMAR.

CONCLUSIONS

Pars plana vitrectomy alone with complete drainage of subretinal fluid achieves a high reattachment rate in the management of primary pseudophakic RRD due to IRBs.

Surgical audit of outcome of rhegmatogenous retinal detachment repair at Vitreoretinal unit JPMC in year 2014

Objective:

To investigate the outcome of rhegmatogenous retinal detachment repair at Vitreoretinal unit of Jinnah Post Graduate Medical Centre Karachi in year 2014.

Methods:

One hundred and three eyes of one hundred and three patients, who underwent three ports parsplana vitrectomy + band + silicone oil, three ports pars plana vitrectomy + silicone oil, three ports pars plana vitrectomy + C3F8 for rhegmatogenous retinal detachment (RRD) repair, at Jinnah Post Graduate Medical Centre, were included in this observational prospective study. Parsplana vitrectomy was done using 23G vitrectomy system. Duration of study was one year. Removal of silicone oil (ROSO) was done on the basis of completely flat retina at least for eight weeks or because of complications due to silicone oil. Patients were followed up post operatively on day one and after one week and then at four weekly interval till the end of the study.

Results:

Anatomical success was achieved in 91 eyes (88.3%). However in 12 eyes (11.7%) retina redetached after removal of silicone oil. Functional success achievement of visual acuity of 3/60 or better was achieved in 85 (82.5%) of eyes post operatively after removal of silicone oil or absorption of gas C3F8 as the case may be.

Conclusion:

Re-detachment is common after removal of silicone oil and incidence of re-detachment is related to the degree of preoperative PVR and location of breaks. Re-detachment occurs more commonly if the breaks are inferiorly located as compared to the superior ones.

Vitrectomy combined with endolaser or an encircling scleral buckle in primary retinal detachment surgery: a pilot study

PURPOSE

To compare pars plana vitrectomy and 360° endolaser therapy with pars plana vitrectomy and an encircling scleral buckle for the treatment of primary rhegmatogenous retinal detachments in a randomized pilot study including 60 patients.

METHODS

Main outcome measures were single-surgery anatomic success rate and final best-corrected visual acuity at 6 months follow-up. Cofactors analysed were complication rates, patients' comfort, refractive outcome and macula status assessed using a spectral-domain optical coherence tomography.

RESULTS

With differences between both treatment groups regarding type of the retinal detachment, localization of retinal tears (p = 0.0085) and the choice of the intraocular tamponade (p < 0.0202), there were no significant differences between the single-surgery anatomic success rate (93.33% both groups, p = 1.0) and the visual acuity at final follow-up (≤0.3 logMAR [logarithm of minimum angle of resolution] in 66.67% in the endolaser group versus 40.0% in the scleral buckle group, p = 0.0514). Questionnaire responses showed lower levels of patients' discomfort in the endolaser group. A significant difference between both groups was found in the refractive error change after surgery (-0.20 ± 0.51 dioptres in the endolaser group versus -0.88 ± 0.88 dioptres in the scleral buckle group, p = 0.0003).

CONCLUSION

Primary vitrectomy combined with 360° endolaser therapy seems to be as effective as vitrectomy combined with an encircling scleral buckle in patients with rhegmatogenous retinal detachment, with possible benefits of an improved patients' comfort and a more stable refractive status after surgery.

Vitrectomy with or without encircling band for pseudophakic retinal detachment: a multi-centre, three-arm, randomised clinical trial. VIPER Study Report No. 1--design and enrolment

PURPOSE

Scleral buckling is currently used in addition to vitrectomy for the treatment of pseudophakic retinal detachment (PRD) to better support the vitreous base and better visualisation of the periphery.

AIMS

The aims of this study are to evaluate (1) whether the combination of 20 G vitrectomy and scleral buckling is superior to 20 G vitrectomy alone (control) (confirmatory), and (2) whether transconjunctival 23/25 G vitrectomy is non-inferior to 20 G vitrectomy (both without scleral buckling) regarding operation success (exploratory).

METHODS

The VIPER (Vitrectomy Plus Encircling Band Vs. Vitrectomy Alone For The Treatment Of Pseudophakic Retinal Detachment) study is an unmasked, multi-centre, three-arm randomised trial. Patients with PRD were eligible, excluding complicated retinal detachment or otherwise severe ophthalmologic impairment. Patients were randomised to one of three interventions: 20 G vitrectomy alone (control C), combination of 20 G vitrectomy and circumferential scleral buckling (experimental treatment E1) or 23/25 G vitrectomy alone (experimental treatment E2). The primary endpoint is the absence of any indication for a retina re-attaching procedure during 6 months of follow-up. Secondary endpoints include best corrected visual acuity, retina re-attaching procedures, complications and adverse events.

RESULTS

From June 2011 to August 2013, 257 patients were enrolled in the study. The internet randomisation service assigned 100 patients each to the treatment arms C and E1, and 57 patients to treatment E2. The imbalance is due to the fact that several retinal surgeons did not qualify for performing E2. The random assignment was stratified and balanced (ie, 1:1 or 1:1:1 ratio) by surgeon.

CONCLUSIONS

The described study represents a methodologically rigorous protocol evaluating the benefits of three different vitrectomy approaches to PRD. The projected results will help to establish their overall efficacy and will permit conclusions regarding their relative value.

TRIAL REGISTRATION NUMBER

DRKS00003158 (German Clinical Trials Register, DRKS).

[Scleral buckling for inferior rhegmatogenous retinal detachments]

PURPOSE

To investigate the epidemiological, clinical, therapeutic and prognostic factors in cases of inferior rhegmatogenous retinal detachments (RD) treated by scleral buckling surgery.

PATIENTS AND METHODS

A retrospective chart review was performed on 45 patients (45 eyes) with inferior RD with only inferior tears (4:00-8:00), who had been treated by scleral buckling surgery over a 6-year period from 2006 to 2011. The parameters studied included patient demographics, refractive status, time until consultation, clinical exam data, treatment modalities and functional and anatomic results.

RESULTS

Forty-five cases were included in this study (45 eyes), with an average patient age of 44.5 years (14 to 75 years) and a slight male predominance (56%). Myopia was observed in 60%. Mean time until consultation was 3.5 months. Visual acuity on admission was less than 1/10 in 53.33%. Macular detachment was found in 80%. Causative lesions were holes in 26 eyes. Proliferative vitreoretinopathy was essentially stage B in 48.9%. Scleral buckling surgery was performed in all patients, with drainage of subretinal fluid in 37.8%. Retinal reattachment was obtained in 36 eyes (80%) with a final visual acuity greater than or equal to 1/10 in 71.11%. The mean follow-up in our study was 6.62 months.

CONCLUSION

Inferior retinal detachment has a predilection for young myopes. The time until consultation is often long, and extraocular surgery, although difficult, exhibits documented efficacy.

Major challenges in vitreoretinal surgery

Since the first vitrectomy surgery was used for treatment of vitreoretinal diseases, surgical techniques and instrumentation have been rapidly improved in the past decades. However, there are complicated vitreoretinal diseases that cannot be successfully treated, even with state-of-the-art surgeries. The outcomes of some complicated cases are still poor due to different reasons and debates still remain in some areas regarding what are the best treatments. There is still a lack of full understanding on many complicated vitreoretinal diseases, such as the molecular basis of proliferative vitreoretinopathy (PVR), the role of scleral buckling (SB) in the management of rhegmatogenous retinal detachment (RRD), the optimal surgical consideration for pediatric RD, and the possibility of surgical management for various retinal degenerations and congenital retinal anomalies. This review discusses the current understandings of some complicated vitreoretinal diseases.

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.

A comparison of the anatomic successes of primary vitrectomy for rhegmatogenous retinal detachment with superior and inferior breaks

PURPOSE

To compare the anatomic success between repair of rhegmatogenous retinal detachment (RRD) with superior breaks and repair of RRD with inferior breaks, by performing primary vitrectomy and using similar techniques and the same gas.

METHODS

Eighty-two consecutive eyes of 80 patients with RRD were included in this retrospective comparative study. The eyes were divided into two groups according to the location of the breaks: superior (n = 62) and inferior (n = 20). All the patients underwent a standard, 3-port, 20-gauge pars plana vitrectomy with 20% sulphur hexafluoride gas tamponade performed by the same surgeon. The main outcome measured was the primary anatomic reattachment at 3 months after surgery.

RESULTS

The primary anatomic success rate in the inferior group was significantly lower than that in the superior group (80% versus 98%, p = 0.012). In the inferior group, the primary anatomic success rate in patients whose symptoms lasted for more than 2 weeks was significantly lower than that in others (5/9 versus 11/11, p = 0.026). Multivariate logistic regression analysis identified inferior break as the only independent risk factor for redetachment (odds ratio, 11.88; p = 0.034).

CONCLUSION

The anatomic success of primary vitrectomy for RRD with inferior breaks is lower than that for RRD with superior breaks. In particular, the duration of symptoms longer than 2 weeks is associated with a worse outcome in patients who had RRD with inferior breaks.

Scleral buckling versus vitrectomy for macula-off rhegmatogenous retinal detachment as accessed with spectral-domain optical coherence tomography: a retrospective observational case series

BACKGROUND

Scleral buckling surgery and pars plana vitrectomy are competing methods in the treatment of retinal detachment. The recent development of spectral-domain optical coherence tomography (SD-OCT) has dramatically improved the visualization of the photoreceptor layer relative to conventional OCT, and offers new opportunities to investigate the discordances between anatomic and functional outcomes after retinal detachment surgery. Hence, the study aim was to use SD-OCT to compare the postoperative macular recovery between scleral buckling and vitrectomy for macular-off rhegmatogenous retinal detachment.

METHODS

In this retrospective observational case series, we observed 32 patients who underwent scleral buckling surgery (group 1) and 26 patients who underwent pars plana vitrectomy (group 2) as the primary surgery for macula-off rhegmatogenous retinal detachment. OCT was used to examine microstructural changes in the macular area.

RESULTS

The mean visual acuity improvement was 0.4 ± 0.8 logMAR in group 1 and 0.7 ± 0.9 logMAR in group 2. As detected by SD-OCT, subretinal fluid was present in 26 of the group 1 eyes (81.3%) and 5 of the group 2 eyes (19.2%) at 8 weeks postoperatively.This difference was statistically significant (Fisher's exact test, P < 0.05). Moreover, detection by SD-OCT revealed epiretinal membranes in 5 of the group 1 eyes (15.6%) and 11 of the group 2 eyes (42.3%), a difference that was statistically significant (Fisher's exact test, P < 0.05).

CONCLUSIONS

Macular recovery and the mean visual acuity differed between the 2 groups of patients. With the help of SD-OCT, we observed that subretinal fluids could persist for a relatively longer period after scleral buckling. Based on our results, we conclude that primary vitrectomy surgery is a better choice for macular recovery of the macula-off rhegmatogenous retinal detachment.

Short-term external buckling with pneumatic retinopexy for retinal detachment with inferior retinal breaks

PURPOSE

To introduce a new approach for short-term external scleral buckling with pneumatic retinopexy for the management of rhegmatogenous retinal detachment with inferior retinal breaks.

DESIGN

Retrospective, noncomparative, interventional case series.

METHODS

A review of 33 consecutive eyes of 31 patients who underwent external buckling with pneumatic retinopexy for uncomplicated rhegmatogenous retinal detachment with inferior retinal breaks from December 2006 through December 2010. An external buckle was made of a 505 sponge sutured along the blunt side of a 279 tyre (MIRA Inc). The buckle was inserted deeply into the inferior fornix without suture after pneumatic retinopexy and was kept in place for 3 days. Primary and final anatomic outcomes, visual acuity, and adverse events were recorded.

RESULTS

All patients tolerated the procedure. The mean follow-up period was 24.0 months (range, 9 to 61 months). Primary success, defined as successful retinal reattachment within 6 months without further treatment, was achieved in 29 (87.9%) eyes. All patients attained final retinal reattachment (100%). Overall, the mean best-corrected visual acuity improved significantly at the end of follow-up (0.30 logarithm of the minimal angle of resolution units; Snellen equivalent, 6/12), compared with the preoperative best-corrected visual acuity (0.82 logarithm of the minimal angle of resolution units; Snellen equivalent, 6/38; P < .001).

CONCLUSIONS

Short-term external buckling with pneumatic retinopexy is a novel and effective treatment for rhegmatogenous retinal detachment with inferior retinal breaks, with a comparable success rate with other treatment methods. This approach also can avoid complications of long-term buckle implantation. Further comparative cohort studies may be necessary to compare the clinical efficacy with other conventional operations.

Primary vitrectomy for the treatment of retinal detachment in highly myopic eyes with axial length over 30 mm

OBJECTIVE

To assess the functional and anatomical outcome of primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment (RRD) in highly myopic eyes with axial length over 30 mm.

METHODS

In this retrospective, interventional case series, we evaluated the outcome of primary vitrectomy without scleral buckling in 67 highly myopic patients (67 eyes) with RRD. Anatomical success rate was defined as complete reattachment of the retina without definitive silicone oil tamponade.

RESULTS

Retinal reattachment was achieved with a single surgery in 49 of 67 eyes (73.1%) and after 2 or 3 surgeries in 54 eyes (80.6%). The characteristics of retinal tears did not influence the final outcome. Multivariate analysis revealed that a longer axial length was the only factor associated with a higher failure rate, p = 0.0061. Mean preoperative visual acuity significantly increased after surgery, p = 0.0003.

CONCLUSION

The study demonstrated fair efficacy of vitrectomy and fluid-gas exchange in the treatment of retinal detachment in highly myopic eyes with an axial length over 30 mm.