Vitrectomy Without Scleral Buckling for Primary

Rhegmatogenous Retinal Detachment

Richard F. Escoffery, M.D., R. Joseph Olk, M.D., M. Gilbert Grand, M.D.,and Isaac Boniuk, M.D.

Trans pars plana vitrectomy with air-fluid ex­change was performed on 29 selected cases of pri­mary rhegmatogenous retinal detachment in whichscleral buckling would be the usual surgical ap­proach. The group contained 20 phakic eyes, twoaphakic eyes, and seven pseudophakic eyes; themacula was detached preoperatively in 17 eyes(66%). The reattachment rate after one operationwas 79% (23 of 29 eyes); after two operations thisincreased to 93% (27 of 29 eyes). Visual acuities of20/50 or better were achieved in 22 of 27 successfullytreated cases (81%). Vitrectomy without scleralbuckling may allow retinal reattachment with excel­lent visual results in selected cases of primary rheg­matogenous retinal detachment.

THE MODERN ERA of retinal detachment surgerybegan in the 1920s with the demonstration by JulesGonin' that ignipuncture could result in retinal reat­tachment in approximately 60% of cases. With thistechnique the sclera was perforated with a hot cau­tery, producing drainage of subretinal fluid withresultant chorioretinal contact at the break. Perma­nent chorioretinal adhesion at the break was ob­tained as a result of the thermal injury created by thecautery. Since Custodis" developed the segmentalepiscleral buckle, modifications of the buckling tech­nique have become the procedures of choice to pro­duce chorioretinal contact at the break. Transscleralcryoretinopexy" is the most frequently used methodof inducing chorioretinal adhesion at the break.

Rosengren! used an intravitreal air injection toachieve closure of retinal breaks and to facilitatechorioretinal contact. This technique plus cryopexyhas been used without buckling in selected detach-

Accepted for publication Jan. 11, 1985.From the Department of Ophthalmology, Washington Univer­

sity School of Medicine, St. Louis, Missouri.Reprint requests to Richard F. Escoffery, M.D., 4949 Barnes

Hospital Plaza, Suite 17413 East Pavilion, St. Louis, MO 63110.

ments but is most often used as an adjunct to scleralbuckling procedures."

Cibis" used intravitreal techniques for the manage­ment of retinal detachment, but it was not until theintroduction of microinstrumentation by Machemerand associates? in 1971 that pars plana vitrectomyachieved a degree of sophistication. This techniqueallowed a new approach to the elimination of vitre­ous traction in retinal detachment surgery. Initiallyused to remove vitreous opacities such as chronichemorrhage, vitrectomy has become the procedureof choice for tractional retinal detachment, especiallythose cases associated with diabetic retinopathy orthose complicated by proliferative vitreoretinopathy.

Considerable experience has been gained in theuse of vitrectomy plus air-fluid exchange for therepair of such retinal detachments. This hydraulicmethod of reattachment has been popularized byCharles." Machemer" and Harris, de Bustros, andMichels" used this technique to repair retinal detach­ment secondary to macular holes, and Benson andTasman" successfully used vitrectomy without ther­mal adhesion to repair three cases of shallow posteri­or retinal detachment with small tears. O'Grady12described a case of retinal detachment with giant tearthat was successfully repaired with vitrectomy andan intravitreal mixture of sulfur hexafluoride and airwithout scleral buckling. Kloti l 3,14 used vitrectomywith internal drainage and air-fluid exchange toachieve hydraulic reattachment of the retina in se­lected cases of retinal detachment. Retlnotomies"were sometimes made to facilitate complete evacua­tion of subretinal fluid and total air-fluid exchange.

Scleral buckling remains the surgical procedure ofchoice in patients with conventional retinal detach­ments. However, this procedure can be complicatedby intraoperative and postoperative events that ulti­mately impair visual function. A combination offactors may result in extrusion, 16 intrusion, 17 or infec­tion" of exoplant material. Motility problems may beinduced by these exoplants or by disinsertion ordamage to extraocular muscles in the course of sur­gery.!" External drainage of subretinal fluid may

©AMERICAN JOURNAL OF OPHTHALMOLOGY 99:275-281, MARCH, 1985 275

276 AMERICAN JOURNAL OF OPHTHALMOLOGY March, 1985

result in subretinal hemorrhage, retinal incarcera­tion, or a retinal break." Encircling elements mayreduce retinal blood flow, as shown by Dopplerstudies;" and result in anterior segment ischemia,especially in patients with hemoglobinopathies. 22 Re­fractive changes are the rule after scleral bucklingprocedures" and may be especially problematic if asignificant degree of anisometropia is induced inpreviously emmetropic eyes. Buckling elements mayresult in distortion of the macula and reduction inmacular function; further, buckling procedures havebeen associated with postoperative cystoid macularedema." which may account for delayed return ofvisual acuity after retinal reattachment.

Vitrectomy offers certain potential advantagesover scleral buckling in that it affords a direct ap­proach to vitreous traction. This traction may beeliminated rather than indirectly diminished as inscleral buckling. The vitreous approach allows inter­nal drainage of subretinal fluid, avoids perforation ofthe choroid, and requires no exoplant material. Vit­reous opacities may be removed at the time of vitrec­tomy and postoperative reaction is usually less thanwith scleral buckling procedures.

Our study was prompted by the success of vitrec­tomy in patients with traction detachments or otherspecialized detachments.

Subjects and Methods

Vitrectomy without scleral buckling was per­formed on 31 eyes in 31 patients with primary rheg­matogenous retinal detachment. All 31 eyes wouldotherwise have required conventional scleral buck­ling. There were 15 males and 16 females, aged 14 to84 years (mean age, 55.4 years). The right eye wasinvolved in 18 patients and the left in 13 patients.

Follow-up lasted at least six months in 29 of the 31cases (mean length of follow-up, 9.6 months). Theother two patients, who were excluded from thestudy, both had reattached retinas at the time of theirlast examinations, but one was lost to follow-upbefore six months and the other, a 66-year-old manwith leukemia, died before his six-month follow-upexamination.

Of the 29 eyes included in the study, 20 werephakic, two were aphakic, and seven were pseudo­phakic. The macula was detached in 19 and attachedin ten. All 29 patients had rhegmatogenous detach­ments. The causative breaks were holes in retino­schisis in three patients, dialysis in two patients,breaks associated with lattice degeneration in 15patients, and other breaks in nine patients. Thecausative breaks were superior (10 to 2 o'clock merid­ians) in 19 patients, horizontal (2 to 4 o'clock or 8 to10 o'clock meridians) in eight patients, and inferior(4 to 8 o'clock meridians) in two patients. Twenty-oneof 29 patients had at least one break posterior to theequator and in eight patients all breaks were anteriorto the equator.

Bimanual trans pars plana vitrectomy with eitherthe Ocutome or the Microvit system was used toachieve a core vitrectomy followed by removal of anyvitreous adherent to the margins of retinal breaks.Hydraulic reattachment was done by means of inter­nal drainage of subretinal fluid through an existingretinal hole in 26 of 29 patients (Fig. 1). In threepatients the retinal breaks were too anterior to allowsafe internal drainage. Two of these three breakswere drained externally; the third patient underwentintentional retinotomy followed by internal drain­age. We used the flute needle" or extrusion system"for internal drainage and air-fluid exchange in allcases.

Chorioretinal adhesion was achieved by transscler­al cryoretinopexy applied to all breaks and areas of

Fig. 1 (Escoffery and associates). In­ternal drainage of subretinal fluid usingair-fluid exchange to achieve hydraulicreattachment of the retina.

Vol. 99, No.3 Vitrectomy Without Scleral Buckling 277

lattice degeneration. We tried to achieve complete airfilling of the vitreous cavity at the completion of theprocedure. In general, cryopexy was applied afterthe retina was reattached to minimize dispersion ofpigment and possibly viable cells from the retinalpigment epithelium (B. M. Glaser, J. Vidaurri-Leal,and R. G. Michels, unpublished data). If the retinacould be flattened and approximated to the choroidby means of internal drainage during a fluid-fluidexchange (as was often the case in single-breakretinal detachments), then cryotherapy was appliedbefore air-fluid exchange to avoid prolonged dura­tion of the cryofreeze as a consequence of ai~ insula­tion. 12•26

A standard (Machemer or Charles) contact lensprovided adequate visualization through air in apha­kic eyes and a -90-diopter (Landers) contact lenswas used for visualization through air in phakic andpseudophakic eyes. General anesthesia was used in21 patients and local anesthesia in eight.

Because of preexisting cataract and miotic therapy,the retina could not be visualized in one patient. Thediagnosis of detachment was made by history andultrasound, and pars plana lensectomy was per­formed at the time of vitrectomy to achieve visualiza­tion of the retina and repair of detachment.

Results

Twenty-three of 29 retinas (79%) were reattachedfor at least six months with a single surgical proce­dure (trans pars plana vitrectomy) (Figs. 2 and 3).The cause of failure in the remaining six patients waspreexisting proliferative vitreoretinopathy (twocases), missed or new breaks (three cases), andinadequate air filling (one case). A repeat air-fluidexchange successfully reattached the retina in oneeye and conventional scleral buckling was successful

Fig. 2 (Escoffery and associates). Pho­tomontage of retinal detachment secon­dary to retinoschisis. Top, Preoperativeappearance, with macula detached anda large hole in the outer wall. Bottom,Postoperative appearance with maculareattached and outer wall hole sealed bycryopexy scar.

278 AMERICAN JOURNAL OF OPHTHALMOLOGY March, 1985

Fig. 3 (Escofferyand associates). Pho­tomontage of retinal detachment secon­dary to large temporal disinsertion.Top, Preoperative appearance withmacula detached and Grade B prolifera­tive vitreoretinopathy present. Bottom,Postoperative appearance with retinareattached and disinsertion sealed bycryopexy scar. Postoperative visual acu­ity was 20/50+2 despite subretinaI pig­mentation in the macula.

in reattaching three of the remaining five detachedretinas.

After two procedures, the reattachment rate was 27of 29 (93%). Two eyes in which the retinas remaineddetached despite initial vitrectomy and subsequentscleral buckling were the only two in this series thathad marked or massive proliferative vitreoretinopa­thy" preoperatively (Grade C1 and Grade D1).

Visual acuities of 20/50 or better were achieved in22 of 27 eyes (81%) with reattached retinas. Of the 17successfully treated eyes in which the macula wasdetached preoperatively, 13 (76%) attained visualacuities of 20/50 or better at the last postoperative

visit. Of the ten successfully treated eyes in whichthe macula was attached preoperatively, nine (90%)achieved visual acuities of 20/50 or better at the lastpostoperative visit.

Inadequate air filling in one patient resulted infailure of the initial procedure. In reviewing thiscase, we think it likely that during closure of thesclerotomies the infusion was inadvertentlyswitched from air to fluid, resulting in incomplete airfilling at the conclusion of the surgical procedure.Subsequent scleral buckling was successful in reat­taching the retina in this patient.

Choroidal effusion developed during surgery in

Vol. 99, No.3 Vitrectomy Without Scleral Buckling 279

one patient in whom a 2.5-mm infusion cannula wasused. This cannula was replaced with a 4-mm cannu­la with no untoward consequences.

Postoperative vitreous hemorrhage resulted inerythroclastic glaucoma in one patient. Anteriorchamber washout was unsuccessful in managing thisproblem and ultimately lensectomy and vitreouswashout were performed. At the time of clearing themedia, the retina was attached and the patient'ssubsequent course was uncomplicated. The source ofthe vitreous hemorrhage was not found, but it mayhave resulted from prolonged cryotherapy in anair-filled eye.

A flat anterior chamber occurred postoperativelyin one aphakic eye with a sector iridectomy. Theanterior chamber failed to re-form spontaneously,and after three days it was surgically re-formed bytranslimbal injection of sodium hyaluronate with a30-gauge needle. This was accomplished under slit­lamp visualization with the patient given topicalanesthesia.

Mild premacular fibroplasia occurred in two eyeswith postoperative visual acuities of 20/60-2 and20150 respectively. One other eye developed a macu­lar cyst with a resultant postoperative visual acuityof 20/300. Fibrinous iritis requiring treatment withoral corticosteroids occurred in one eye. Inadequatecryopigmentation around the retinal break occurredin one patient and six weeks postoperatively wastreated with supplemental argon laser photocoagula­tion with the patient given topical anesthesia. Therewere no complications.

Significant cataract occurred two months postoper­atively in one eye and a mild posterior subcapsularcataract developed eight months postoperatively inanother. In general, we avoided the vitreous ap­proach in eyes with posterior subcapsular cataractfor fear of worsening the lens opacity. 28

Discussion

The reattachment rates of 79% (23 of 29 retinas)and 93% (27 of 29 retinas) obtained in the presentseries with one and two operations respectively werecomparable to the usual reattachment rates quotedfor scleral buckling. Hilton, McLean, and Ncrton'"reviewed a series of 600 cases of rhegmatogenousretinal detachment treated by scleral buckling andfound reattachment rates of 84% and 91% with oneand two operations respectively.

Both of the eyes in the present series with Grade Cor D proliferative vitreoretinopathy preoperativelyfailed to achieve retinal reattachment despite initialvitrectomy and subsequent scleral buckling. On the

basis of this initial series, it would seem that retinaldetachment complicated by proliferative vitreoreti­nopathy to this degree should not be managed bytrans pars plana vitrectomy and air-fluid exchangewithout concomitant scleral buckling. With the twocases of proliferative vitreoretinopathy Grade C1 andGrade D1 eliminated from the series, our reattach­ment rates would have been 85% (23 of 27) and 100%(27 of 27) with one and two operations respectively.

It seems noteworthy that visual acuities were 20150or better in 22 of 27 successful cases (81%) after thisprocedure. This compares quite favorably with visualresults obtained with scleral buckling procedureswhere 56% may be expected to achieve this level ofvision. 29 Thirteen of 17 patients (76%) with detachedmaculas preoperatively obtained visual acuities of20150 or better and nine of ten (90%) with maculasattached preoperatively, achieved 20150 or better.These results again compare favorably with the re­sults of scleral buckling, where 42% of those withdetached maculas and 72% of those with attachedmaculas are expected to achieve this level of visualacuity."

The type of retinal detachment must be taken intoconsideration. Patients with schisis retinal detach­ments may have large irregular holes in the outerwall, often posterior to the equator and occasionallyin close proximity to the macula. In such patients,scleral buckling requires a posterior plombage thatmay result in macular disturbance. Trans par planavitrectomy with air-fluid exchange allows repair ofthese cases without buckling. If the holes in the innerwall are small and anterior, as is often the case, thenretinotomy of the inner wall may be used to facilitateinternal drainage.

Pseudophakic retinal detachments can presentspecial problems for conventional buckling as well asfor vitrectomy. Iris-fixated lenses may be displacedanteriorly in the course of air-fluid exchange withresultant damage to the corneal endothelium. Suchcontact can be prevented by initially placing a tempo­rary fixation suture across the anterior chamber.j"Such a suture is not required for the usual anteriorchamber or posterior chamber intraocular lens.

Eyes in which retinal breaks are entirely anterior tothe equator pose problems for the vitreous approach.It may be difficult to remove traction from anteriorbreaks, especially in phakic eyes in which the poten­tials for lenticular touch and, eventually, cataract aresignificant. Similarly, internal drainage is also diffi­cult to perform through anterior breaks. Exposure ofan anterior break during surgery may be facilitatedby use of a prismatic contact lens (Tolentino), bychanging the axis of the microscope, by tilting theoperating table, or by the use of concomitant scleralindentation. Indirect ophthalmoscopy may also facil-

280 AMERICAN JOURNAL OF OPHTHALMOLOGY March, 1985

itate visualization during internal drainage throughthese anteriorly located breaks.

Postoperatively, patients are positioned to keepthe air bubble in contact with the retinal break for aslong as possible. This is readily accomplished inpatients with superior breaks who can lie with thehead of the bed elevated, sit, or stand erect postoper­atively. Patients with inferior retinal breaks requirepositioning that may be much more uncomfortableand difficult. Such patients require total air filling orthe use of a sulfur hexafluoride-air mixture toachieve air tamponade of the inferior tear for a longenough period. Although most such patients canremain either supine or prone, occasionally Trende­lenberg positioning may be required.

It should be recognized that there are potentiallyhazardous complications of this procedure. Whereasthe complications typically associated with conven­tional scleral buckling may be avoided, other compli­cations such as cataract, angle closure, iatrogenicbreak formation, vitreous hemorrhage, endothelial­intraocular lens contact, endophthalmitis, and possi­bly sympathetic ophthalmia may conceivably berelated to a trans pars plana approach. In our experi­ence to date, these complications appear to be rareand most can be avoided. Further experience andlonger follow-up are required to ascertain the ulti­mate frequency and significance of such events.

Our series was composed of selected cases ofprimary rhegmatogenous retinal detachment, con­sisting of sequential patients who were treated bythis technique. However, not every patient withretinal detachment examined at our office underwentrepair by this method. Strict criteria have yet to bedeveloped to determine which patients are bettermanaged by vitrectomy as opposed to a conventionalscleral buckle. However, patients with significantvitreous opacities, patients with special breaks, orthose with significant vitreous traction on the breakmay apparently be best managed by this method.The ultimate visual function achieved in this seriessuggests that other types of retinal detachment nowtreated by conventional buckling may also benefitfrom this procedure. A larger series of patients fol­lowed up for longer intervals is required before thisdetermination can be made. Until that time, becauseof the inherent hazards of the procedure, it is ourrecommendation that this approach be attemptedonly by surgeons experienced both in vitrectomy andscleral buckling. However, it appears clear that transpars plana vitrectomy offers an alternative to con­ventional scleral buckling in selected cases of pri­mary rhegmatogenous retinal detachment. It is pos­sible that visual results may be better than thoseobtained with conventional buckling and that some

of the complications associated with scleral bucklingcan be avoided by this technique.

References

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