cuatro tecnicas quirurgicas

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PRIMARY RETINALDETACHMENT REPAIR

Comparison of 1-Year Outcomes of FourSurgical Techniques

SHLOMIT SCHAAL, MD, PHD, MARK P. SHERMAN, MD, CHARLES C. BARR, MD,

HENRY J. KAPLAN, MD

Purpose: To compare functional and anatomical outcomes of modern methods of repair

of primary retinal detachment.

Materials and Methods: Retrospective interventional comparative case series. A total

of 1,226 patients with primary retinal detachment were included in the study. All patients

completed 1-year follow-up and were divided into 4 groups: 322 patients underwent scleralbuckling surgery, 442 patients underwent pars plana vitrectomy surgery, 316 patients

underwent a combination of scleral buckling and vitrectomy surgery, and 56 patients

underwent pneumatic retinopexy surgery for the primary repair of retinal detachment.

Reattachment success rates, pre- and postoperative visual acuity, complications, and

change in refractive error were reviewed.

Results: Initial success rate for retinal reattachment was 86% for scleral buckling only,

90% for vitrectomy only, 94% for the combination of scleral buckling and vitrectomy, and

63% for pneumatic retinopexy surgery. Although patients undergoing pneumatic

retinopexy had a lower initial success rate, there was no statistically significant difference

in initial reattachment rates between the other three groups. There was no statistically

significant difference in final visual acuity between the four groups. Complication rates

varied among the techniques used.

Conclusion: Postoperative visual acuity at 1 year did not differ among the various

techniques used to repair primary rhegmatogenous retinal detachments. However, scleralbuckling, vitrectomy, or a combination of both resulted in an initially better anatomical

success rate and fewer operative procedures than pneumatic retinopexy.

RETINA 31:15001504, 2011

Treatment of primary retinal detachment continues

to be of interest to vitreoretinal surgeons,

comprising about half of all surgical cases in

vitreoretinal surgery departments and practices.1

Modern techniques of primary retinal detachment

repair allow most detachments to be repaired

successfully. Although most techniques show high

reattachment rates, each procedure has its own

drawbacks and complications. About 40% of patients

may not achieve reading ability, 10% to 40% may need

.1 surgical procedure, and approximately 5% of eyes

will have permanent anatomical and functional

failure.2

Few studies39 to date have compared modern tech-

niques of primary retinal detachment repair in regard

to their technical and visual success rates and in-

cidence of complications at 1 year. Primary retinal

detachment repair techniques include scleral buckling

alone, pars plana vitrectomy alone, a combination of

scleral buckling and pars plana vitrectomy, and pneu-

matic retinopexy. We conducted the current retro-

spective case series involving four different surgeons

to compare the results using different modern primary

From the Department of Ophthalmology and Visual Sciences,University of Louisville, Louisville, Kentucky.

Presented in part at the Retina Society Meeting, Scottsdale, AZ,2008.

Supported in part by an unrestricted grant from Research toPrevent Blindness, Inc, New York, NY.

Reprint requests: Shlomit Schaal, MD, PhD, Department ofOphthalmology and Visual Sciences, University of Louisville, 301East Muhammad Ali Boulevard, Louisville, KY 40202; e-mail:[email protected]

1500


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retinal detachment repair techniques. While retinal

fellows participated to some extent in each case, an

attending physician was present during the entire

procedure.

Methods

Inclusion Criteria

The medical records of 1,226 patients with retinal

detachment who underwent primary repair at the

University of Louisville, Louisville, KY, between the

years 1996 and 2009 were reviewed. Patients who had

diabetic retinopathy, proliferative vitreoretinopathy,

giant retinal tears, combined retinal and choroidal

detachments, or previous ocular trauma were excluded

from the present study. The remaining patients were

divided into 4 groups: 356 patients underwent scleral

buckling surgery, 479 patients underwent vitrectomysurgery, 331 patients underwent a combination of

scleral buckling and 20-gauge vitrectomy surgery, and

60 patients underwent pneumatic retinopexy surgery

for the primary repair of their retinal detachment.

There were no differences in the baseline clinical and

anatomical characteristics of the patients in the four

groups, although those undergoing pneumatic retino-

pexy had superior retinal breaks. The average visual

acuity at presentation and the percentage of macula-off presentations, which ranged between 54% and

58% and the extent of detachment, did not differ

among the 4 groups (no statistical significance). Thechoice on which primary procedure to perform was

dependent on the surgeons preference. This study was

approved by the institutional review board of the

University of Louisville.

Interventions

For scleral buckling, varying silicone sponges and/

or encircling bands were used according to the

surgeons preferences. Retinopexy of breaks was

performed either with cryopexy or with indirect laser

retinopexy. Optional surgical steps included intraoc-

ular injection of balanced saline solution, air, or sulfur

hexafluoride, drainage of subretinal fluid, and anterior

chamber paracentesis.

Pars plana vitrectomy using Alcon Accurus vitrec-

tomy system was performed either as standard 3-port

sclerotomies or as transconjunctival 25-gauge surgery

involving the insertion of transscleral cannulas using

a beveled trocar after displacement of the conjunctiva.

All eyes underwent core vitrectomy followed by

elevation and removal of the posterior hyaloid

membrane, if necessary. Subretinal fluid was drained

through existing retinal breaks or retinotomies. A 20%

sulfur hexafluorideair mixture was used as endotam-

ponade, and endolaser was used for retinopexy. Use of

heavy liquids was optional.

A combination of scleral buckling and vitrectomy

included the suturing of an encircling buckle of

varying width followed by a 20-gauge 3-port parsplana vitrectomy, internal drainage of subretinal fluid,

endolaser, and a 20% sulfur hexafluorideair mixture

for endotamponade as described above. The use of

a fourth port intraocular chandelier lighting was

optional.

Pneumatic retinopexy patients were chosen accord-

ing to the presence of retinal breaks within 1 clock

hour of retinal arc in superior quadrants without other

retinal breaks. These patients were treated in an office

setting as described by Hilton and Tornambe5 and

others3,4 using a subconjunctival or retrobulbar

anesthesia supplemented by topical anesthesia. Aninjection of 0.3 cc of 100% C3F8 gas was used as

endotamponade. Either laser retinopexy or cryopexy

was used to treat retinal breaks, and patients were

instructed to assume the appropriate head position.

Outcome Measures

Of the initial cohort of 1,226 patients, 1,136completed 1-year of follow-up and were the subjects

of this analysis. Retinal reattachment and final visual

acuity were the primary outcome measures. Compli-

cations that were recorded included increased in-traocular pressure .21 mmHg that required treatment

after 2 weeks, change in manifest refraction, cystoid

macular edema, or epiretinal membrane formation as

determined by clinical examination, fluorescein

angiography, or optical coherence tomography, and

development of cataract that was clinically significant

or required cataract extraction within the 1-year

follow-up period.

Statistics

Statistical analysis was performed using SPSSsoftware (Version 11.0) for Microsoft Windows.

Differences between the groups were calculated using

Friedman test. Statistical significance was accepted if

P , 0.05.

Results

The results of our primary outcome measures are

shown in Table 1. A total of 1,136 patients completed

at least 1 year of follow-up, while 90 patients (7%)

PRIMARY RETINAL DETACHMENT REPAIR SCHAAL ET AL 1501


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were lost to follow-up. Of the 1,136 patients, 540 were

phakic and 596 were pseudophakic.

As shown in Table 1, success rates for scleral

buckling, vitrectomy and combined vitrectomy and

scleral buckling procedures ranged from 86% to 94%.

However, there was no statistically significant differ-

ence between the anatomical success rates of these

three procedures. The anatomical success rate for

pneumatic retinopexy was significantly loweronly

63% were anatomically attached after this procedure(P , 0.05). There was no statistically significant

difference between the average initial visual acuity

measured for the different groups, except for the

pneumatic retinopexy group which had significantly

better starting vision. All groups had improved final

visual acuity after 1 year of follow-up, with no

statistically significant difference in final average

vision between the 4 groups. This study has not

compared the visual acuity between the macula-on

cases, and the macula-off cases. There was no

statistically significant difference in intraocular pres-sure measurements between the 4 groups throughout

the 1 year of follow-up. There was no difference in

results depending on the primary surgeon (data not

shown).

Scleral buckling with or without vitrectomy had

a statistically significant increase in postoperative

refractive change and cystoid macular edema when

compared with vitrectomy alone (P , 0.05). By

contrast, 1 of 4 phakic patients (25%, 79 patients)

developed cataract after 1 of the vitrectomy proce-

dures, while only 8% (14 patients) had cataract

progression after a scleral buckle (P , 0.05) Surgery

time was significantly increased (43 minutes longer in

average) for the combined vitrectomy and scleral

buckling group (P , 0.05).

Figure 1 summarizes the percentage of procedures

performed during the study period. There wasa continuous decline in the percentage of scleral

buckling for the repair of primary retinal detachment

from 52% of cases in 1996 to 11% in 2008, with

a concomitant increase in the number of primary

vitrectomies. The percentage of combined proceduresor pneumatic retinopexies did not change.

This study was not designed to determine what

caused failure of initial retinal detachment repair. Not

all patient records documented the reason for surgical

failure, although new retinal tears and proliferative

vitreoretinopathy accounted for most of the docu-

mented reasons for failure. Most initial failures were

repaired after 1 additional surgery (85%), while 12%

needed 2 additional procedures (12%), and 3% needed

$3 procedures.

Discussion

Randomized trials comparing scleral buckling,

vitrectomy, and pneumatic retinopexy as treatment

for primary retinal detachment are infrequent.6,9 In

previous studies, one procedure could not be demon-

strated as clearly superior to another. Therefore, the

selection of scleral buckling, vitrectomy, or pneumatic

retinopexy for primary retinal detachment remains

a subjective decision made by the surgeon, weighing

the variables of each case.

Table 1. Characteristics of Patients Undergoing Different Surgical Procedures

Scleral Buckle VitrectomyScleral Buckle

and Vitrectomy Pneumatic Retinopexy

Number of patientswho completed 1-year follow-up

322 442 316 56

Number of patients

lost for follow-up

34 (9%) 37 (7%) 15 (4%) 4 (5%)

Number phakic 175 (54%) 204 (46%) 120 (38%) 41 (73%)Number pseudophakic 147 (46%) 238 (54%) 196 (62%) 15 (27%)

Anatomical success rate 86% 90% 94% 63% Average initialvisual acuity

20/400 20/400 20/400 20/80

Average finalvisual acuity

20/50 20/40 20/50 20/30

Increased IOP 11% 6% 5% 6%Change in refraction 33% 2% 14% 0%CME 16% 4% 29% 0%Cataract 8% 21% 28% 0%ERM 5% 10% 18% 0%Surgery time 64 minutes 68 minutes 120 minutes NA

IOP, intraocular pressure; CME, cystoid macular edema; ERM, epiretinal membrane; NA, not applicable.

1502 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2011 VOLUME 31 NUMBER 8


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In this study, eyes with noncomplex rhegmatoge-

nous retinal detachments underwent a primary repair

by one of four modern surgical techniques. The

success rate for retinal reattachment was not statisti-cally different for vitrectomy (both 20 gauge and 25

gauge), scleral buckling or combined vitrectomy and

scleral buckling (ranging from 86% to 94%). Thesuccess rate for pneumatic retinopexy was signifi-

cantly lower (63%, P , 0.05).

In their summary of 1,274 eyes in 26 published

reports on pneumatic retinopexy performed between

1986 and 1989, Hilton et al5 found single-operation

success for pneumatic retinopexy to range from 53%

to 100%. While our primary success rate with

pneumatic retinopexy was inferior to those reported

in the pneumatic retinopexy trial, they are in keeping

with those reported in the Southeast Wisconsin study9

and the study of Ross and Lavina,7 who reported

a 51% success rate with pneumatic retinopexy.Although our study shows that our pneumatic

retinopexy patients having similar final visual acuities

as the other procedures, this is partly because of the

required use of additional procedures to achieve

a desirable outcome for many patients.

Approximately 40 of our 1,136 patients underwent

25-gauge vitrectomy to repair retinal detachment. The

technical and visual results in this group did not differ

from the 20-gauge group, which is in keeping withrecently published studies by Miller et al10 and by

Lai et al.11

This report is also the first to document theincidence of complications of retinal reattachment

surgery in the modern era. Significant differences were

found in incidence of and type of postoperative

complications (Table 1). We found that the scleral

buckling procedure resulted in refractive change in

one third of the cases. Vitrectomy, however, had

a minimal impact on patients refraction. The scleral

buckling procedure, whether alone or in combinationwith vitrectomy had significantly higher incidence of

cystoid macular edema. We can only speculate as to

the cause of increased cystoid macular edema inpatients with scleral buckle. Possible factors include

an increased amount of inflammatory mediators in the

vitreous cavity and the increased tissue manipulation

that is part of the scleral buckling procedure. The

vitrectomy procedure, with or without scleral buckling

had a higher incidence of cataract formation. Most

patients (142 patients of 210) in our series who

developed visually significant cataract underwent

cataract surgery, and final visual results were good.

Epiretinal membranes have been found histologi-

cally in 60% to 75.5% of successful retina reattach-

ment eyes postmortem.12,13

We found clinicallyapparent epiretinal membranes in up to 18% of

successfully reattached eyes and were surprised by the

relatively high number of eyes developing this

complication after otherwise successful vitrectomy.

Final visual acuity was rarely affected; however; only

11 patients required vitrectomy and removal of these

epiretinal membranes.

Our report also shows a declining trend in the use of

scleral buckle for primary retinal detachment repairwith an increased use of vitrectomy (Figure 1). This

finding can be attributed to the fact that scleral

buckling requires more tissue manipulation and resultsin greater refractive changes than vitrectomy. Also, the

instrumentation used in vitrectomy surgery has

improved over time. The introduction of 25-gauge

vitrectomy has decreased the necessity of suturing and

may have increased surgeons preference of vitrec-

tomy over scleral buckling.

At our institution, all patients receive the same care in

the same hospital regardless of ability to pay. Nonethe-

less, in our geographic area, vitrectomy and vitrectomy

combined with scleral buckling are reimbursed at

a higher rate than scleral buckling alone. That this and

the patients ability to pay may have played an

unconscious role in the surgeons choice of procedure

cannot be discounted. As vitreoretinal specialists, we

are aware that vitrectomy procedures are inherently

more expensive than scleral buckling and pneumatic

retinopexy because of equipment and necessary

supplies. Although vitrectomy is becoming a more

common procedure for uncomplicated primary retinal

detachment repair, scleral buckle is still favored in

certain cases, such as inferior retinal tears. When

discussing these procedures one has to keep in mind that

higher single-operation success rate may not indicate

Fig. 1. Percentage of different retinal reattachment procedures per-formed during the years under study. SB, scleral buckle; Vit, vitrec-tomy; Comb, combined vitrectomy and scleral buckle; PR, pneumaticretinopexy.

PRIMARY RETINAL DETACHMENT REPAIR SCHAAL ET AL 1503


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superiority of a specific procedure, especially if the total

cost of the surgery and reoperations are included. In the

present study, postoperative morbidities such as

diplopia, micropsia, or anesthesia-related morbiditywere not assessed. These may be important in selecting

the specific procedure to repair a retinal detachment in

the individual patient. Cautious case selection and wiseclinical judgment remain invaluable in tailoring

a specific surgical technique to our patients.

Although there was no statistically significant

difference in visual acuity or technical success,

combined vitrectomy and scleral buckling had the

highest initial technical success rate of 94%. As seen in

Table 1, however, this procedure took almost twice as

long as scleral buckling or vitrectomy alone and had

much higher rates of complications. This is in keeping

with the work of Weichel et al,14 who also found

a higher complication rate in patients undergoing scleral

buckle combined with vitrectomy. Although pars planavitrectomy is currently the preferred surgical technique

for primary retinal detachment repair at our institution,

we continue to select the procedure that we believe

meets the needs of the individual patient. We look

forward to future investigations that will enable us to

reattach retinas with higher success rates, better final

vision, and fewer complications.

Acknowledgment

The authors thank Tongalp H. Tezel, MD, whose

patients were included in this study.

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1504 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2011 VOLUME 31 NUMBER 8

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cuatro tecnicas quirurgicas