Strategy for the Management of Uncomplicated Retinal Detachments

Acta Ophthalmologica Scandinavica, 2006

The British journal of ophthalmology, 2015

retinal detachment (RRD) is a common clinical challenge that affects up to one of every 170 people. 1 RRD treatment is one of the most common indications for vitreoretinal surgery, and such repair is one of the most cost-effective practices in the treatment of all vitreoretinal disorders. Retinal reattachment surgery is unusual among ophthalmic surgeries because excellent outcomes may be obtained using three distinct approaches: scleral buckling (SB) first described in the 1950s, 5-7 pars plana vitrectomy (PPV) first reported in 1971 8 and pneumatic retinopexy (PR) first reported in 1986. 9 Core surgical principles for RRD management include identification and treatment of all retinal breaks. PPV is increasingly employed in the repair of primary RRD. A 2012 US Medicare claims database analysis reported 74%, 11% and 15% of primary RRD being repaired with PPV, SB and PR, respectively, 11 with substantial regional differences. Given the expansion of PPV use, vitreoretinal fellows are being exposed to fewer SB procedures. In a 2010 survey of 66% of USA vitreoretinal fellows, it was reported that 39% performed <20 SB and 22% performed and assisted in <40 primary SB. 12 Despite this evolving trend in surgical exposure during training, many surgeons still use SB. The 2015 Preferences and Trends survey revealed 67% of surgeons place an SB in 11% or more of RRD surgeries, with 24% placing an SB in 41% or more of RRD surgeries. While high surgical success rates can be achieved with each technique, all approaches to primary RRD repair have less than perfect success rates: 10-40% of eyes require more than one surgical procedure, and as many as 5% of eyes may sustain permanent anatomic and functional failure despite favourable surgical timing and technical expertise. 14 Regardless of surgical approach, anatomic single operation success rate (SOSR) is influenced by pre-existing RRD characteristics. For example, high-risk RRD with giant retinal tear or in the presence of proliferative vitreoretinopathy (PVR) has a well-documented lower SOSR, 15 and more common clinical findings such as inferior retinal breaks, increasing number of retinal breaks and extent of RRD appear to reduce SOSR. In comparison to medical retinal diseases, surgical retinal diseases have less commonly been subjected to the scrutiny of large, prospective randomised clinical trials (RCTs). Furthermore, few prospective analyses have compared the different approaches to RRD repair. 17 18 For a surgical trial, standardisation of techniques among surgeons is a major challenge. The current analysis aims to synthesise published data and incorporate recent observational reports into a clinical guide for optimal decision-making when considering primary RRD surgical options.

Revista Sociedade Portuguesa de Oftalmologia, 2017

Rhegmatogenous retinal detachment (RRD) remains a major cause of emergency assistance in our ophthalmology departments. We struggle for the improvement of visual outcome of our patients after RRD surgery by trying to optimize our surgical methods and techniques. The decision of which surgical procedure to use in the treatment of RRD still depends on a variety of factors and surgeon's preference. Until date there was only one major randomized clinical trial that drew some guidelines for our clinical practice. This present work has the main purpose of reviewing the major articles published so far on RRD surgery with the goal of creating a rational for our day practice for the best functional and anatomic results. Although many variables are involved in RRD treatment, prospective, multicentric, randomized studies are needed.

British Journal of Ophthalmology, 2008

Aims: To assess variations in the characteristics and management of two series of non-complicated rhegmatogenous retinal detachments (RD) carried out 4 years apart in Spain. Methods: Prospective, multicentric, non-randomised comparative study. 339 consecutive cases of RD treated in five hospitals were included. Group 1 (G1) (n = 186) included cases operated on from 1999 to 2001; group 2 (G2) (n = 153) included cases from 2004 to 2006. 83 variables related to preoperative characteristics of RD, surgical management and postoperative evolution were recorded. Surgeons were allowed to treat patients following their personal criteria. Differences in preoperative characteristics, rate of vitrectomy and anatomical outcome were studied. Quantitative variables were compared by Mann-Whitney U test and qualitative variables by standard contingency tables. Multivariate analysis was carried out by logistic regression analysis. Results: G1 showed a significantly longer delay in performing surgery, since the first symptoms appeared (G1: 29 (SD 50) days; G2: 22 (55); p,0.001) and more RD without visible retinal break than G2 (G1: 17.4%; G2: 9.2%; p = 0.028). In G2, cases with multiple retinal breaks (G1: 31.6%; G2: 44.6%) were more frequent (p = 0.022). No significant differences in other preoperative variables were observed. Vitrectomy was performed in 30.1% in G1 and in 78.4% in G2 as a primary surgical approach (p,0.001). Regardless of the characteristics of the RD, the rate of vitrectomy was higher in G2. The reattachment rate was over 94% in both groups (p = 0.833). Pseudophakic RD showed better anatomical outcomes in G2 (G1: 83.9%; G2: 96.4%; p = 0.028). Conclusion: There is an increasing tendency to treat RD with primary vitrectomy, which is related to neither a higher complexity of cases nor better anatomical results.

American Journal of Ophthalmology, 2011

MICHAEL KINORI, ELAD MOISSEIEV, NADAV SHOSHANY, IDO DIDI FABIAN, ALON SKAAT, ADIEL BARAK, ANAT LOEWENSTEIN, AND JOSEPH MOISSEIEV • PURPOSE: To compare pars plana vitrectomy (PPV) with combined PPV and scleral buckle (SB) for the repair of noncomplex primary rhegmatogenous retinal detachment (RRD

PubMed, 2017

Purpose: To report the primary and final success, functional outcome and complication rates of patients with primary rhegmatogenous retinal detachment (RRD) who underwent retinal detachment surgery in a tertiary referral centre in Northern Ireland. Venue: Vitreoretinal service, Royal Victoria Hospital, Belfast, Northern Ireland. Methods: This is a retrospective case series of all patients who underwent primary RRD repair between 1st of January 2013 and 31st of December 2013. Charts were reviewed. Patients' demographics, overall primary and final success, functional outcome, complication rates were identified and recorded. Subgroup analysis according to lens status and foveal attachment was also performed. Results: A total of 212 cases of primary RRD were included. Mean age at time of surgery was 56.6 years (range 9-90 years); 175(82.5%) had pars plana vitrectomy (PPV), 27 (12.5%), scleral buckle (SB) repair and 10 (5%) pneumatic retinopexy (PR). Overall primary and final success rate were 86% and 95.6% respectively. Overall mean visual acuity improved from 1.1 to 0.4 LogMAR postoperatively after a mean follow-up of 9 months. There was no significant difference in the primary success rate in relation to the baseline lens status (χ2 = 3.4, P = 0.2) and to the baseline macular status (χ2 = 0.6, P = 0.7). Presence of proliferative vitreoretinopathy (PVR) negatively affected the primary success rate (χ2=7.2, P = 0.03). Poor prognostic factors for success were PVR at presentation, inferior breaks and increasing number of detached quadrants. Conclusions: This study demonstrates a success rate comparable with other centres with a low rate of final failure. Despite sub-specialism and the great advances in VR surgery, the biology of RRD dictates a failure rate. New therapies may improve results in the future.

2018

Purpose: To investigate the outcomes and success rate of surgical intervention for patients diagnosed with primary rhegmatogenous retinal detachment. We investigate the most common and current procedures: pneumatic retinopexy (PR), pars plana vitrectomy(PPV), scleral buckle(SB), and combined vitrectomy and scleral buckle(SB+PPV). Methods: This nonrandomized, retrospective case series was conducted using data from a single retina surgeon at Beth Israel Deaconess Medical Center. Patient data was collected from September 1999-October 2017. The main inclusion criteria were diagnosis with a primary (meaning it is a first RD experienced by the eye) RRD and subsequent treatment with scleral buckle, vitrectomy, pneumatic retinopexy, or a combination of scleral buckle and vitrectomy (SBV). Patients who have experienced a prior RD, trational RD, or RD due to trauma were excluded from this study. Preoperative and postoperative VA was compared using a logarithm of the minimum angle of resolution (logMAR) score. sixty patients underwent PR treatment (n=60), sixty patients were treated with a combination of SB+PPV (n=60), fifty-two were treated with PPV vii (n=52) alone, and fifty-four had SB (n=54) treatment. A successful outcome was a complete reattachment of the retina in subsequent follow-up appointments based on comprehensive fundus exams and ocular coherence tomography (OCT) scan. Results: Our study showed significant success rates across all four potential surgeries. PR having a success rate of 48/60 (72%), SB+PPV with 53/60 (88%), PPV at 41/52 (77%), and SB showing 41/54 (79%). Starting visual acuity for PR was .67, Combined SB+PPV patients started with 1.4, PPV patients had a 1.84 logMAR score, and SB patients had a starting visual of 1.82. Patients undergoing PR treatment had a lower occurrence of mac-off RRD at 55%. While patients who underwent combined SB+PPV, vitrectomy alone, and SB had higher rates of mac-off RRD at 67%, 60%, and 58% respectively. Conclusions: Our study demonstrated good outcomes for all surgical procedures used. While the type of surgery performed will depend on a case-by-case determination. The results of our study showed improvement in visual acuity in patients after treatment for primary rhegmatogenous retinal detachment (RRD). Overall, the results of our study demonstrate very good outcomes for patients treated with PR, vitrectomy, SB, and

Current Surgery Reports, 2015

Recognition of vitreoretinal traction and retinal breaks in the pathogenesis of rhegmatogenous retinal detachment (RRD) by Gonin in 1919 ushered in the era of surgical treatment. Since then multiple treatment strategies including scleral buckling (SB), pars plana vitrectomy (PPV), and pneumatic retinopexy have evolved. While all are effective treatments, much attention has shifted to determining the best treatment for a patient based on factors such as lens status and presence of complicating factors such as choroidal detachments, proliferative vitreoretinopathy, multiple tears, significant hypotony, or presence of giant retinal tears. Thus far the available data suggest that for uncomplicated phakic detachments both PPV and SB are reliable options, though due to cataract formation SB may be favorable in these patients. For pseudophakic RRDs, the data seem to suggest PPV has a higher single operation success rate than SB. Moreover in complicated RRDs, PPV has a more favorable outcome.

BMC Ophthalmology, 2016

Background: Pars plana vitrectomy (PPV) is preferred surgical procedure for the management of complex rhegmatogenous retinal detachment (RRD). The purpose of this study was to evaluate the anatomical results of primary PPV for the treatment of primary complex RRD and to determine the influence of lens status, tamponading agent, preoperative proliferative vitreoretinopathy (PVR) and axial length (AL) of the eye upon the anatomical outcome. Methods: A retrospective consecutive chart analysis was performed on 117 eyes from 117 patients with complex RRD managed with PPV. Fifty-nine eyes were phakic and 58 pseudophakic eyes. All patients had a minimum follow-up period of 12 months. Eyes were classified into groups using independent variables (first classification based upon lens status and tamponade used, second classification based upon lens and PVR status and third classification based upon AL of the eye). The groups were compared for anatomical outcomes (dependent variables) using nonparametric-or, in case of normally distributed data, parametricstatistical tests. Results: Retinal reattachment rate in phakic eyes was 94.9% compared to 93.1% in pseudophakic, with no statistically significant difference between the two. The overall retinal reattachment rate with single surgery was 94.0%. Final reattachment rate was 97.4%. In case of established PVR ≥ C1, the reattachment rate was not statistically different (92.6%) from eyes with no PVR (91.1%) irrespective of lens status. A statistically significant difference was found between redetachment rates only between phakic eyes with gas tamponade compared to silicon oil (SO) (p = 0.001). Reattachment rate proved to be similar in both AL groups (≤24 mm and > 24 mm). Conclusions: High anatomical success rate of primary vitrectomy for complex RRD with either gas or SO tamponade was achieved in phakic as well as pseudophakic eyes irrespective of AL of the eye.

Graefe's Archive for Clinical and Experimental Ophthalmology, 2001

Background: In patients with more complex rhegmatogenous retinal detachments (RRD) not complicated by proliferative vitreoretinopathy (PVR), the most appropriate operating method is controversial, and different surgeons use different techniques. The Scleral Buckling Versus Primary Vitrectomy in Rhegmatogenous Retinal Detachments Study (SPR Study) is designed to compare primary vitrectomy and scleral buckling techniques in these patients. Methods: The SPR Study is a multicentre, randomised, controlled clinical trial stratified by lens status. Patients with RRD which is not complicated by PVR grade B or C and which cannot be treated with a single meridional sponge are randomised to either scleral buckling or pars plana vitrectomy as first surgical intervention. Four hundred consecutive patients are to be recruited per subtrial (phakic and aphakic/pseudophakic patients), and followed up for 1 year. The primary endpoint (functional outcome) is the change in visual acuity. Secondary endpoints (anatomical outcome) include postoperative PVR, retinal reattachment and the number of reoperations necessary to achieve retinal reattachment. Twenty-seven institutions (49 surgeons) in six European countries have been recruited for participation in the study. Conclusion: The SPR Study is the first randomised prospective clinical trial to compare scleral buckling and primary vitrectomy in patients with RRD. The results of this study should enable vitreoretinal surgeons to improve the surgical therapy of patients with the more complicated manifestations of RRD.