The Safety and Efficacy of Adjustable Postoperative Position after Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment

Practice of postoperative face-down positioning and its duration after silicone oil tamponade in vitreoretinal surgery: Results of a survey

PURPOSE

This survey was conducted among practicing vitreoretinal (VR) surgeons to determine their practice of postoperative face-down positioning (FDP) of patients and its duration after silicone oil (SO) tamponade.

METHODS

A web-based SurveyMonkey platform (San Mateo, CA, USA) was used for this cross-sectional study. Up to 80 practicing VR surgeons in the Kingdom of Saudi Arabia (KSA) and Pakistan were contacted via SurveyMonkey link using WhatsApp and emails.

RESULTS

Of the 80 practicing VR surgeons, 71 responded to the survey. All VR surgeons in both countries use SO in their surgical practice. While operating on complicated retinal detachments (RDs) that include cases with advanced proliferative vitreoretinopathy, 75% of VR surgeons choose SO tamponade, while 9% of VR surgeons prefer gas tamponade. Up to 63% of VR surgeons advise FDP to their patients whenever they use SO as tamponade. When operating on complicated RDs with SO tamponade, 79% of VR surgeons advise postoperative FDP. Roughly half of the VR surgeons advise FDP for 6 to 10 days. The duration of postoperative FDP varies from 1 day to 21 days.

CONCLUSION

All VR surgeons use SO in their practice in KSA and Pakistan. While the vast majority of VR surgeons in both countries use SO as tamponade for complicated RDs, the practice of postoperative FDP and its duration appears to be quite variable. This highlights a lack of uniformity in postoperative care of these patients.

Outcomes of Primary Vitrectomy for Rhegmatogenous Retinal Detachment With No Postoperative Positioning

Purpose: To evaluate the anatomic and visual outcomes of primary vitrectomy for rhegmatogenous retinal detachment (RRD) repair using no amount of postoperative prone positioning to clarify the role of face-down posturing for RRD reattachment. Methods: This retrospective consecutive interventional case series comprised patients who had primary vitrectomy for RRD repair. The surgical outcomes, single-surgery anatomic success rate, and postoperative best-corrected visual acuity (BCVA) were assessed. The primary objective was to evaluate the anatomic and visual outcomes of vitrectomy RRD reattachment using no postoperative prone positioning. Results: This study comprised 116 eyes of 116 patients. Single-surgery anatomic success was achieved in 112 (96.5%) of 116 eyes. The single-surgery anatomic success rate was 100% in phakic patients (n = 56) and 93% in pseudophakic patients (n = 60), with both groups having an improvement in the mean BCVA. Conclusions: Primary vitrectomy with no postoperative prone positioning is a successful surgical intervention for RRD repair. The anatomic closure rate in this study is one of the highest reported in the literature and involved a large number of macula-off RRDs, with minimal complications and a significant improvement in BCVA, primarily using 14% perfluoropropane for gas tamponade.

A Comparison of Adjustable Positioning and Free Positioning After Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment: A Prospective Randomized Controlled Study

Purpose

To compare the effectiveness and safety of adjustable and free postoperative positioning after pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD).

Design

Prospective, randomized controlled study.

Methods

A total of 94 eyes with RRD were enrolled from April 2020 to April 2023 and monitored postoperatively for at least 3 months. All patients underwent PPV combined with silicone oil injection or gas tamponade and were randomly divided postoperatively into two groups: an adjustable positioning group and a free positioning group. The success of the outcome was based on the retinal reattachment rate, best corrected visual acuity (BCVA), postoperative complications, and ocular biometric parameters such as anterior chamber depth (ACD) and lens thickness (LT).

Results

The initial retinal reattachment rate was 97.9% in the adjustable positioning group and 95.7% in the free positioning group, manifesting no statistical difference between the two groups. Similarly, no statistical difference was observed between the two groups in the final BCVA, which was significantly improved compared to the preoperative BCVA. The comparison of the 1-month postoperative ACD and LT with the preoperative values showed no statistically significant differences in the two groups. The rates of complications were not statistically different in the two groups.

Conclusion

After treating RRD using PPV, neither the adjustable nor the free postoperative positioning affected the retinal reattachment rate or the incidence of complications. Therefore, our study showed that it is safe and effective to adopt free positioning postoperatively, which may provide more options for patients with RRD undergoing PPV.

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.

Effect of surgical timing in 23-g pars plana vitrectomy for primary repair of macula-off rhegmatogenous retinal detachment, a retrospective study

BACKGROUND

Rhegmatogenous retinal detachment (RRD) is a common, potentially blinding ocular pathology that is considered a surgical emergency. Macular involvement has been identified as a major negative prognostic indicator for visual recovery after RRD correction. It is not currently clear whether early intervention improves visual outcomes, and in practice, there are potential disadvantages to performing early surgery for fovea-involving RRD. Such disadvantages include inadequate assessment of coexisting comorbidities, increased rate of complications related to poorly trained staff or tired surgeons, and anesthetic risk.

METHODS

A single-center, retrospective, cohort study of patients who underwent repair of macula-involving rhegmatogenous retinal detachment at the University of Virginia was performed. Variables collected included patient demographics, ocular history, clinical characteristics, and post-operative complications. Patients were excluded if they had a history of congenital or acquired pathology with an effect on visual function, bilateral or repeat rhegmatogenous detachment, age less than 18 years, follow up duration less than 6 months, or if they were repaired using scleral buckle, pneumatic retinopexy, 25- or 27-gauge pars plana vitrectomy, or any combination of these techniques. A multivariate regression model was used to compare overall outcomes such as post-operative visual acuity, intra-ocular pressure, retina attachment status, and complications among patients of differing timing of surgical repair. These analyses were adjusted for clinical factors known or considered to be associated with worse prognosis in rhegmatogenous retinal detachment.

RESULTS

A total of 104 patients undergoing 23-gauge vitrectomy for repair of macula involving rhegmatogenous retinal detachments were included in this study with mean follow up period 17.9 ± 14.1 months. Early surgical repair (< 48 h) was pursued in 26 patients, moderately delayed surgical repair (3-7 days), was performed in 29 patients and late surgical repair (> 7 days) in 49 patients. Our analysis showed no difference in post-operative visual acuity between patients with detachments undergoing early versus moderately delayed repair of RRD. However, mean visual acuity differed between patients undergoing early versus late repair at 3, 6, and 12 months. No significant difference was observed in post-operative complications between the three surgical timepoints including cataract formation, development of glaucoma and re-detachment rate. Use of 360 laser was found to be protective against re-detachment overall (OR 6.70 95% CI 1.93-23.2).

CONCLUSIONS

These findings indicate that a moderate delay of 3-7 days from symptom onset for repair of macula-involving retinal detachment may be a safe approach as there are no differences in terms of visual acuity or post-operative complications compared to early repair within 48 h. Delaying surgery for > 7 days however is not recommended due to the loss of recovery of visual acuity observed in this study. Use of 360 laser may prevent risk of re-detachment after primary repair.

A Comparison of Face-Down Positioning and Adjustable Positioning After Pars Plana Vitrectomy for Macular Hole Retinal Detachment in High Myopia

Purpose

To compare the anatomical and functional outcomes of macular hole retinal detachment (MHRD) in high myopia after pars plana vitrectomy (PPV) with face-down positioning and adjustable positioning.

Methods

Fifty-three eyes from 53 patients with MHRD were analyzed in this study. All patients received PPV with silicon oil for tamponade and then subdivided into 2 groups: 28 were included in a face-down positioning group and 25 were included in the adjustable positioning group. Patients were followed up for at least 6 months. The main outcome was the rate of anatomical macular hole (MH) closure and retinal reattachment. Secondary outcome measures were the best-corrected visual acuity and postoperative complications.

Results

There was no significant difference in the rate of MH closure (53.6 vs. 72.0%, p = 0.167) and retinal reattachment (100 vs. 96%, p = 0.472) between the face-down group and adjustable group. Compared with the mean preoperative best-corrected visual acuity (BCVA), the mean postoperative BCVA at the 6-month follow-up improved significantly in both groups (p = 0, both). But there was no significant difference in the mean postoperative BCVA (p = 0.102) and mean BCVA improvement (p = 0.554) at 6 months after surgery between the two groups. There was no significant difference in the high intraocular pressure (IOP) after surgery between the two groups (53.6 vs. 44%, p = 0.487). There were no other complications that occurred during the follow-up.

Conclusion

Adjustable positioning after PPV with silicon oil tamponade for MHRD repair is effective and safe. Face-down positioning does not seem to be necessary for all patients with MHRD.

Feminizing Adrenocortical Tumors as a Rare Etiology of Isosexual/Contrasexual Pseudopuberty

OBJECTIVE

Estrogen-secreting adrenocortical tumors (ACTs) are quite rare with feminizing adrenocortical tumors (FATs) accounting for 0.37-2% of all ACTs. The aim was to evaluate clinical and hormonal characteristics of FATS as well as treatment options and follow-up in the pediatric age group.

METHODS

Medical records of children with ACTs presenting to a single center in the last two decades were reviewed. Literature review within Pubmed revealed 34 pediatric patients (22 boys) with FAT among 192 articles.

RESULTS

Among the 25 children presenting with ACTs in the last two decades, two new pediatric cases of FAT were identified, one benign and the other malignant, in two genders with different clinical presentations. Literature review showed that FATs are extremely rare tumors that are most commonly seen in men and boys presenting with gynecomastia. FATs are more common in children ≤8 years of age, with a median age at diagnosis of six years. While boys present with contrasexual pseudopuberty signs, girls present with isosexual pseudopuberty. A high estrogen level strongly supports diagnosis, while elevations in other adrenal hormones may be seen. FATs are usually malignant in adults and prognosis is generally very poor. However, in children approximately half are benign although assessment of malignant potential depends on clinical behavior of the tumor. FATs are very unpredictable so even after surgery long-term follow-up is required. FATs presenting in childhood may have a better prognosis than adult presentation tumors as most FATs in children are followed without recurrence of tumor.

CONCLUSION

FATs are more common in children ≤8 years of age, with a median age at diagnosis of six years. FATs in childhood may have a better prognosis than in adult males.

Primary rhegmatogenous retinal detachment: evaluation of a minimally restricted face-down positioning after pars plana vitrectomy and gas tamponade

AIM

To evaluate the safety and efficacy of a minimally restricted face-down postoperative positioning following pars plana vitrectomy (PPV) with gas tamponade for primary rhegmatogenous retinal detachment (RRD).

METHODS

Patients with primary RRD treated with PPV and gas tamponade and followed up for at least 6mo were selected for the study. All phakic eyes underwent simultaneous cataract surgery. The patients were required to be in a postoperative position that prevented downward flow of retinal tears. Patients with macular detachment were positioned face-down for only a couple of hours. The patients were assessed for preoperative and postoperative best-corrected visual acuity (BCVA), anatomical retinal reattachment rate, and postoperative complications.

RESULTS

In total, 40 eyes of 39 patients with primary RRD were included in the study. A single tear was present in 30 eyes (75.0%), multiple retinal tears were present in nine eyes (22.5%), and oral dialysis was present in one eye (2.5%). The anatomical success rate was 90.0% (36 cases) after the primary surgery, and the final anatomical success rate was 100%. The BCVA improved significantly (P<0.001) from 0.75 logarithm angle of resolution (logMAR) preoperatively to 0.12 logMAR at the final visit. Postoperative complications included intraocular pressure elevation (≥25 mm Hg) in 11 patients (27.5%), fibrin formation in two patients (5.0%), pupillary capture of the intraocular lens in two patients (5.0%), and posterior synechia in one patient (2.5%).

CONCLUSION

A minimally restricted face-down and flexible postoperative positioning after PPV and gas tamponade for primary RRD is effective and safe.

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.

Functional and morphological results of treatment of macula-on and macula-off rhegmatogenous retinal detachment with pars plana vitrectomy and sulfur hexafluoride gas tamponade

BACKGROUND

To examine morphological and functional results after pars plana vitrectomy (PPV) with sulfur hexafluoride (SF6) gas tamponade due to macula-on and macula-off rhegmatogenous retinal detachment (RRD) during 6 months of the follow-up.

METHODS

The study included 62 eyes that underwent successful PPV with SF6 tamponade with macula-on (34 eyes) and macula-off (28 eyes) RRD preoperatively. The best-corrected visual acuity (BCVA), Amsler test, M-charts, optical coherence tomography (OCT) and microperimetry were performed at 1, 3 and 6 months postoperatively.

RESULTS

Results of the Amsler test were abnormal postoperatively in 54% of the patients in the group with macula-off and in 32% of the patients with macula-on RRD. Horizontal M-charts improved significantly from 0.33 to 0.2, vertical M-charts- from 0.29 to 0.17 during 6 months of the follow-up. There was a significant increase in the central retinal thickness (CRT) and average thickness (AT) between follow-up examinations only in the macula-off group. 29 of 62 eyes (47%) after surgery (equally with macula-on and macula-off RRD) showed morphological changes in OCT in the macular region, as epiretinal membrane, macular edema, subretinal fluid or alterations of the outer layers of the retina. The average threshold in microperimetry increased significantly within both groups during the follow-up.

CONCLUSION

Both horizontal and vertical M-charts scores, as were as microperimetry sensitivity improved significantly during the 6 months of the follow-up both in macula-on and macula-off group. Although PPV with SF6 gas tamponade was successful, almost half of eyes revealed anatomical changes in the macular region in OCT both with macula-on and macula-off group.

TRIAL REGISTRATION

Current Controlled Trials NCT03902795 registered on 03/04/2019. Retrospectively registered.

Air tamponade and without heavy liquid usage in pars plana vitrectomy for rhegmatogenous retinal detachment repair

AIM

To report the results of rhegmatogenous retinal detachment (RRD) repair after pars plana vitrectomy (PPV) without operative use of heavy liquid, and utilizing air tamponade in selected cases.

METHODS

RRD patients without severity of proliferative vitreoretinopathy C₂ or more underwent PPV without operative use of heavy liquid, and utilizing air tamponade were consecutively enrolled. Alternative postoperative facedown position or lateral position was required for 3-5d.

RESULTS

Totally 36 eyes of 36 patients (24 males, 66.7%) aged 53.8±10.9y underwent this modified surgery. The mean number of retinal break was 2.1±1.3. Most of the eyes (29, 80.6%) had retinal detachment involving more than one quadrant. Twenty-two (61.1%) eyes with cataract had combined phacoemulsification and intraocular lens implantation. The mean follow up time was 4.6±1.8mo. Two eyes with retinal redetachment underwent a second retinal repair surgery with silicone oil tamponade, yielding the primary reattachment rate to 94.4% (34/36). Six (16.7%) eyes had intraocular pressure higher than 25 mm Hg. The visual acuity (logMAR) improved from 0.98±0.74 preoperatively to 0.52±0.31 postoperatively (P<0.001).

CONCLUSION

The success rate of this modified retinal repair surgery is comparable with traditional surgery. This technique can be considered for certain retinal detachment patients, since its apparent advantages included lower surgical complications, reduced surgery expenditure, shorter time for postoperative facedown position, and avoiding silicone oil removal surgery.