| | Management of Retinal Detachment When No Break Is FoundReceived 6 May 2005; accepted 3 October 2005. published online 09 January 2006. ObjectiveTo review the results of 2 different surgical approaches in the management of primary rhegmatogenous retinal detachments (RDs) with undetected retinal breaks. DesignRetrospective, consecutive, interventional case series. ParticipantsMedical records of 44 patients with uncomplicated macula-involving primary rhegmatogenous-appearing RDs, but without retinal breaks detected preoperatively or intraoperatively, were reviewed. MethodsAll study patients were operated by the same surgeon between 1989 and 2004 using 2 approaches: 26 (59%) patients underwent a scleral buckling procedure (SBP) with or without subretinal fluid drainage, whereas 18 (41%) patients underwent scleral buckling combined with pars plana vitrectomy (PPV), fluid–gas exchange, and broad application of endolaser. Main Outcome MeasuresSingle operation and final postoperative anatomic success, and 2-month postoperative and final best-corrected visual acuity (VA) (negative logarithm of the minimum angle of resolution [logMAR]). ResultsMean preoperative VAs were 1.73 logMAR units (median, 1.60; range, 0.48–2.60) in the combined surgery group and 1.52 logMAR units (median, 1.30; range, 0.30–2.60) in the scleral buckling group. Neither preoperative (P = 0.33), 2-month postoperative (P = 0.53), best-corrected (P = 0.98), nor final (P = 0.46) mean VA showed any statistically significant differences between the 2 treatment groups. A single operation reattachment rate of 72% (13/18 cases) was achieved in the combined surgery group, compared with 61.5% (16/26 cases) in the scleral buckling group (P = 0.17, log rank test). Immediate anatomic success rates were 89% after combined treatment and 38.5% after scleral buckling alone (P = 0.002). At the final visit, the retina was attached in 15 (83.3%) patients who received the combined treatment and in 22 (84.6%) patients who underwent scleral buckling (P = 0.900). Intraoperative subretinal hemorrhage occurred in 1 (5.6%) patient from the combined surgery group and in 2 (7.7%) patients from the scleral buckling group. Retinal incarceration in the drainage sclerotomy occurred in 1 (3.8%) case during the SBP. Proliferative vitreoretinopathy sufficient to require reoperation developed in 1 (5.6%) eye of the combined surgery group and in 3 (11.5%) eyes of the scleral buckling group. ConclusionsScleral buckling is as effective in the management of uncomplicated rhegmatogenous RDs with undetected breaks as is surgery combining scleral buckling and PPV.
The critical step in successful rhegmatogenous retinal detachment (RD) surgery is to seal the causative retinal break. Despite clear visualization of the fundus, retinal breaks are not found in 2.2% to 4% of phakic RDs.1, 2 In aphakic and pseudophakic RDs, the incidence of nonvisualized breaks is higher, reported as 7% to 16% and 5% to 22.5%, respectively.1, 2, 3, 4, 5, 6 Such cases have traditionally been managed using circumferential buckling and broad application cryopexy, with a reported primary success rate of 53% to 85%.2, 7, 8, 9, 10 The rationale of encirclement is to support unseen retinal breaks that might exist in the periphery by decreasing presumed vitreous traction—as scleral buckling without retinopexy has been reported to effect retinal reattachment in some cases.11 The combination of scleral buckling and pars plana vitrectomy (PPV) in these cases offers the possibility of searching for obscure breaks internally and allows broad retinopexy (laser) with what may be less induced proliferative vitreoretinopathy (PVR), but removes a potential tamponade effect by the vitreous. The results of combined surgery contrast. Some studies report good results12, 13, 14; others conclude that PPV does not allow better detection of the break that was missed preoperatively.8, 15 Another report shows no statistically significant difference between the 2 techniques.16
The purpose of this study was to review and compare the results of these 2 different surgical approaches in the management of primary rhegmatogenous RDs with undetected retinal breaks.
Materials and Methods  The study protocol was approved by the institutional review board of the University of Miami School of Medicine. The charts of all patients operated for rhegmatogenous RDs from 1989 through 2003 by one of the authors (WES) were reviewed (692 patients). This medical record review yielded 44 patients with primary rhegmatogenous macula-involving RDs in which a definite break could not be seen preoperatively or intraoperatively by indirect ophthalmoscopy despite a clear media. All cases with a mention of substantial preoperative media opacities such as vitreous hemorrhage, dense cataract, PVR, recurrent RD, or choroidal detachment were excluded from the study. Patients without macular involvement were excluded, as these 12 were more commonly treated with scleral buckling alone, which may have biased outcomes. Patients managed with vitrectomy alone also were excluded, as this modality was reserved exclusively for eyes that were judged to be too risky for scleral buckling, such as eyes with glaucoma implant devices, or eyes with thin sclera. The patients were analyzed in 2 groups: scleral buckling procedure (SBP) and scleral buckle plus PPV (combined). The decision of which approach to apply was arbitrary, but possibly was biased by the surgeon’s general tendency towards avoiding vitrectomy in primary cases. Excluding the cases as outlined above minimized that possible bias. Cases in which a retinal break or a probable retinal break was found intraoperatively were also excluded; data concerning this scenario were not reliably tabulated, but they far outnumbered the study groups. Thus, cases without breaks were defined narrowly in this study. Data regarding when a decision for management with vitrectomy in addition to scleral buckling was made were not uniformly ascertainable, but usually it was an intraoperative decision to perform vitrectomy. All operations were performed by the same surgeon using monitored anesthesia care. A 360° SBP was done in all the eyes in both groups. In the SBP group, cryopexy of all suspicious areas was performed, and subretinal fluid (SRF) was commonly drained through a sclerotomy, which was closed with a preplaced 6-0 black silk suture. Extensive confluent application of cryopexy generally was avoided. The combined group, additionally, underwent a 3-port PPV. In most cases, a retinotomy was performed with a fine diathermy tip and used for internal SRF drainage during fluid–air exchange. Confluent laser burns were placed along the margins of the retinotomy and along the posterior margin of the buckle at least throughout the meridians of the detachment, but usually for 360°, using an 810-nm diode laser. The following preoperative data typically were recorded in patient charts and were tabulated: patient age, gender, lens status (phakic, pseudophakic, aphakic), refractive error (myopia [<−6 diopters (D)] or high myopia [>−6 D]), extent of RD, duration of macular detachment, and preoperative best-corrected visual acuity (BCVA). Postoperative data collected included intraoperative and postoperative complications, immediate postoperative retinal status (on the first postoperative day), reoperations, final retinal attachment status, BCVA at 2 months postoperatively and at final follow-up examination, and duration of follow-up. All best-corrected Snellen acuity measurements were transformed into the logarithm of the minimum angle of resolution (logMAR) equivalent (negative logMAR) to create a linear scale of visual acuity (VA). Three categories of anatomic outcome were determined: retina flattened, retina not flattened, and retina partially flattened. Partially flattened was defined as when the macula was attached, but SRF persisted elsewhere. Statistical Methods The comparison between the SBP group and the combined group for categorical variables was performed using the chi-square test or the Fisher exact test, and that for continuous variables was performed using Student’s t test. Kaplan–Meier survival analysis was used to compute the rate of reoperation for recurrent RD in both groups, and the reoperation rate between the 2 groups was compared using the log rank test. A P value of <0.05 was defined to be of statistical significance. All statistical analyses were performed using SPSS (version 12, SPSS Inc., Chicago, IL). Results Demographic and baseline characteristics of the 2 groups of patients are summarized in Table 1. A total of 44 eyes of 44 patients were included in this study: 18 in the combined group and 26 in the SBP group. Mean follow-up periods were 8.3 months (median, 5 months; range, 8 days–29 months) for the combined group and 14.9 months (median, 3.4 months; range, 1 day–76 months) for the SBP group. The patients ranged in age from 9 to 92 years (mean, 60) in the combined group and from 13 to 91 years (mean, 68) in the SBP group. In the combined group, the mean preoperative VA was 1.73 logMAR units (median, 5/200; range, 20/60–hand movements [HM]), the mean duration of macular detachment was 31 days (standard deviation [SD], 32.2), 17% of the patients were phakic, 61% were pseudophakic, and 22.2% were aphakic. In the SBP group, the mean preoperative VA was 1.52 logMAR units (median, 20/400; range, 20/40–HM), the mean duration of macular detachment was 36 days (SD, 80.7), 34% of the patients were phakic, 58% were pseudophakic, and 8% were aphakic. There were only 3 phakic patients in the combined group, and 9 in the SBP group. |
⁎
Chi-square test or Fisher exact test.
†
Student’s t test. |
All selected 44 eyes were diagnosed with a macular-involving RD by study design. On the first postoperative day, the retina was attached completely in 16 of 18 (89%) patients and partially attached in the remaining 2 (11%) patients after combined surgery (Table 2). On the first postoperative day, the retina was totally flattened in 10 of 26 (38.5%) patients; 6 (23%) patients showed a partial reattachment; and in 10 (38.5%) eyes, there was still a macula-involving detachment in the SBP group. Thus, immediate postoperative anatomic success was significantly better for the combined group (P = 0.002). |
⁎
Chi-square test or Fisher exact test.
†
Log rank test using Kaplan–Meier survival analysis.
‡
Student’s t test comparing visual acuity in logMAR units. |
The single operation reattachment rate of 72% (13/18 cases) in the combined group was statistically indistinguishable from the 61.5% (16/26 cases) in the SBP group (P = 0.17, log rank test). At 6 months, rates of cumulative attachment not requiring reoperation for recurrent RD were 65% in the combined group and 46.5% in the SBP group. Further PPV for RD was necessary for 5 (27.7%) eyes in the combined group and 10 (38.5%) eyes in the SBP group. The results at 2 months postoperatively also were similar in each group, but reflect many of these reoperations (Table 2). The survival without reoperation, expressed as cumulative percentage (Kaplan–Meier survival analysis) of patients, is shown in Figure 1. At the final visit, the retina was completely attached in 15 (83.3%) patients in the combined group and in 22 (84.6%) patients in the SBP group (P = 0.900). The groups undergoing drainage of SRF or gas injection did not have statistically significant different anatomic outcomes compared with the subgroup counterparts (Table 3). The combined group had a mean BCVA at 2 months of 1.29 logMAR units (SD, 0.72), mean BCVA of 0.97 logMAR units (SD, 0.54), and mean final BCVA of 1.07 logMAR units (SD, 0.72) (Table 2). The SBP group had a mean 2-month postoperative BCVA of 1.14 logMAR units (SD, 0.75), mean best BCVA of 0.96 logMAR units (SD, 0.78), and mean final BCVA of 1.26 logMAR units (SD, 0.84). Preoperative (P = 0.33), postoperative at 2 months (P = 0.53), best (P = 0.98), and final (P = 0.46) mean BCVA did not show any statistically significant differences between the 2 groups. Significant complications encountered during the study included 3 cases of intraoperative subretinal hemorrhage: 1 (5.6%) in the combined group and 2 (7.7%) in the SBP group (Table 4). One (3.8%) case of retinal incarceration in the drainage sclerotomy occurred in the SBP group. Proliferative vitreoretinopathy developed in 1 (5.6%) eye of the combined group and in 3 (11.5%) eyes of the SBP group. Other postoperative complications included epiretinal membrane formation (sufficient to undergo further surgery) in 3 (17%) cases in the combined group and in 1 (3.8%) case in the SBP group, choroidal detachment in 1 (5.6%) combined group patient and 2 (7.7%) SBP group patients, and scleral buckle exposure requiring subsequent removal 6 months after initial surgery in 1 (5.6%) combined group patient. Discussion The inability to detect retinal breaks in a rhegmatogenous RD has been reported to be associated with a prognosis poorer than that of cases in which the break was identified.2 Small breaks, poor mydriasis, cortical remnants, capsular opacification, glare or pitting from the intraocular lens implant, corneal opacification, or vitreous opacities may make identification difficult, especially because anterior breaks more commonly occur in pseudophakic and aphakic RDs. Such cases commonly are managed with vitrectomy techniques. However, despite a clear view, retinal breaks cannot be identified in a small subset. Various strategies have been described to locate unseen retinal breaks. The configuration of the RD is associated with more likely break locations, so the region of the search may be narrowed down.17 Griffith et al described the use of exploratory cryotherapy to highlight and to identify a retinal break as it was enveloped by the developing iceball.7 An internal approach offers some advantages that might result in the detection of breaks. Scleral external indentation together with endoillumination and magnification during PPV may help locate previously undetected breaks.18 Also during vitrectomy, searching with an aspirating instrument or using perfluorocarbon liquids may disclose a stream of fluid exiting the subretinal space via the hole (Schlieren effect).19 Despite these suggestions for the identification of nonvisualized breaks, there continue to be cases in which breaks cannot be diagnosed. Several strategies have been proposed to treat an RD when there are no recognized breaks. Griffith et al performed an SBP with an encircling buckle placed anterior to the equator, 360° cryotherapy, and SRF drainage.7 The success rate of this procedure with one operation was 66%. Wong et al performed a PPV including membranectomy (as indicated), scleral buckling, cryotherapy, and an internal gas tamponade to treat similar cases, with a 60% rate of retinal reattachment.8 Desai and Strassman reported 100% initial success in pseudophakic RDs with undiagnosed breaks by combining SBP with vitrectomy, fluid–gas exchange, and endolaser photocoagulation12; in their study, no patient had significant preoperative PVR. They explained that the combined technique offered the possibility of releasing vitreoretinal traction as well as tamponading unseen breaks. In 1999, Brazitikos et al reported a 100% primary attachment rate combining primary vitrectomy with perfluoro-N-octane use (without scleral buckling) in the treatment of pseudophakic RDs without visible breaks.14 On the other hand, some authors have not found vitrectomy to be of additional value in terms of success rate. Wu et al reported a high success rate with the SBP alone (72%) and concluded that the combined procedure was unnecessary for otherwise routine RD.20 Tewari et al compared the anatomical and visual results of scleral buckling alone versus the combined procedure in patients with RD due to undetected breaks, finding no statistically significant difference in outcomes between the 2 groups, but the number of intraoperative and postoperative complications was higher in the combined surgery group.16 Pars plana vitrectomy without a scleral buckle for primary rhegmatogenous RDs (with identified retinal breaks) has also been described.21, 22, 23, 24, 25 The 2 groups of patients considered for comparison in the current study were similar, and comparable to other studies with respect to macular involvement (in both groups, only macula-off RDs were included), duration of macular detachment (P = 0.79), and preoperative VA (P = 0.33)—all factors that consistently have been shown to influence anatomic and visual success rates.26, 27, 28 The reattachment rate with one operation was not statistically better with a scleral buckle alone or the combined surgical strategy (P = 0.17). The higher anatomic results on the first postoperative day in the combined group were equalized by the 2-month and final follow-up visits. Visual acuities at 2 months and best and final BCVAs were also similar for both strategies. Thus, these findings are in agreement with Wong et al8 and Tewari et al16 in that no clear advantage in terms of anatomic or visual outcomes could be attributable to combining PPV and scleral buckling, compared with conventional scleral buckling techniques alone, for eyes with RDs due to unseen breaks. Complication rates were similar in both groups in this study. Neither strategy offered an overwhelming advantage on the basis of success or complication rates; only the inevitability of cataract extraction (CE) in the combined group—it is widely recognized that vitrectomy accelerates the formation of nuclear sclerosis—differed convincingly.29 Thus, the need for CE is anticipated in each of these cases with in a few months, whereas those in the SBP group would not be expected to require cataract surgery much sooner than if they had not needed RD surgery. The number of phakic cases in the current study was too small to allow a meaningful comparison. There are several barriers preventing a more definitive assessment of the question explored by this study. Practice trends have shifted, with what seems to be a more common bias towards vitrectomy (alone or in combination with scleral buckling) among more recently trained vitreoretinal surgeons. There is no clear evidence-based justification for that shift. This study has related the divergence of results in the literature. A prospective randomized trial at a limited number of centers would seem impractical due to the low rate of case ascertainment. However, a larger group of centers may introduce heterogeneity in diagnosis and management that may similarly confound an answer. Beyond that, in this study there was a 10% difference in success rate that was not statistically significant, due to the relatively small sample size of cases. However, a prospective randomized study expecting to demonstrate such a difference with an 80% or 90% power would require 800 or 1000 patients. A 20% difference would require 200 or 300 patients. Thus, it seems unlikely that such a study would be performed, given the finding that only about 5% of patients met these study criteria. 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MEDLINE Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida  Correspondence to William E. Smiddy, MD, Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101-6880
Manuscript no. 2005-395. No author has any financial or intellectual conflicts of interest in the material presented herein. PII: S0161-6420(05)01174-7 doi:10.1016/j.ophtha.2005.10.002 © 2006 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved. | |
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