Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

25-Gauge Vitrectomy and Incomplete Drainage of Subretinal Fluid for the Treatment of Primary Rhegmatogenous Retinal Detachment

Stratos Gotzaridis, MD; Efstathios Liazos, MD, FEBOphth; Petros Petrou, MD; Ilias Georgalas, MD, PhD

Abstract

BACKGROUND AND OBJECTIVE:

To evaluate the anatomical and functional results of 25-gauge (G) vitrectomy with incomplete drainage of subretinal fluid for the treatment of primary rhegmatogenous retinal detachment.

PATIENTS AND METHODS:

A retrospective, noncomparative interventional case series including 100 consecutive patients who underwent 25-G vitrectomy, incomplete drainage of subretinal fluid, cryolaser or endolaser, and SF6 gas tamponade for the treatment of primary rhegmatogenous retinal detachment was performed.

RESULTS:

Fifty-six percent of retinal detachments were macula-on and 44% were macula-off. Fifty-six percent of patients were phakic and 44% were pseudophakic. Primary anatomical success rate was 94%, and the final success rate was 100%. Mean preoperative visual acuity was 0.75 logMAR, and mean postoperative visual acuity was 0.39 log-MAR (P < .001).

CONCLUSION:

Incomplete drainage of subretinal fluid during vitrectomy for the treatment of primary rhegmatogenous retinal detachment does not seem to influence the anatomical success rate. On the contrary, it minimizes the surgical maneuvers, thus reducing perioperative complications.

[Ophthalmic Surg Lasers Imaging Retina. 2016;47:333–335.]

Abstract

BACKGROUND AND OBJECTIVE:

To evaluate the anatomical and functional results of 25-gauge (G) vitrectomy with incomplete drainage of subretinal fluid for the treatment of primary rhegmatogenous retinal detachment.

PATIENTS AND METHODS:

A retrospective, noncomparative interventional case series including 100 consecutive patients who underwent 25-G vitrectomy, incomplete drainage of subretinal fluid, cryolaser or endolaser, and SF6 gas tamponade for the treatment of primary rhegmatogenous retinal detachment was performed.

RESULTS:

Fifty-six percent of retinal detachments were macula-on and 44% were macula-off. Fifty-six percent of patients were phakic and 44% were pseudophakic. Primary anatomical success rate was 94%, and the final success rate was 100%. Mean preoperative visual acuity was 0.75 logMAR, and mean postoperative visual acuity was 0.39 log-MAR (P < .001).

CONCLUSION:

Incomplete drainage of subretinal fluid during vitrectomy for the treatment of primary rhegmatogenous retinal detachment does not seem to influence the anatomical success rate. On the contrary, it minimizes the surgical maneuvers, thus reducing perioperative complications.

[Ophthalmic Surg Lasers Imaging Retina. 2016;47:333–335.]

Introduction

Small-gauge, sutureless vitrectomy is becoming more popular among surgeons for the treatment of a broad spectrum of vitreoretinal disorders. The 25-gauge (G) transconjuctival sutureless vitrectomy system was initially introduced by Fujii et al.,1 followed by the introduction of the 23-G system by Eckardt.2 The advantages of small-gauge vitrectomy over the traditional 20-G vitrectomy include shorter surgical time, faster postoperative recovery, and increased patient comfort. This can be applied to the treatment of retinal detachments.

The aim of vitrectomy for the treatment of a rhegmatogenous retinal detachment is to identify the retinal break/breaks, to eliminate the traction from the area of the break/breaks, to reposition the retina, perform retinopexy over the responsible break/breaks, and tamponade the retina either by using expansile gas or silicone oil. However, it still remains controversial whether it is necessary to drain the subretinal fluid (SRF) during the fluid-air exchange.

Several techniques have been suggested for the drainage of SRF. This can be achieved through the main break, either via drainage retinotomies or by using perfluorocarbon liquids to displace the SRF. However, several disadvantages have been reported to be related to the above techniques. Posterior retinotomies have been associated with proliferative vitreoretinopathy and visual field defects,3 and perfluorocarbon liquids may be toxic to the photoreceptors, the retinal pigment epithelium (RPE), and the cornea4,5 and occasionally can be displaced subretinally, leading to retinal toxicity and absolute scotomas. Of course, residual subretinal fluid may lead to macular folds and microfolds, especially in cases when caution is not given to postoperative head-posturing.

The aim of the present study was to investigate the anatomical and visual outcomes of 25-G vitrectomy for the treatment of rhegmatogenous retinal detachment with incomplete drainage of subretinal fluid, without the use of draining retinotomies or perfluorocarbon liquids.

Patients and Methods

A retrospective, interventional, consecutive case series was conducted, involving 100 patients with primary rhegmatogenous retinal detachment. The study adheres to the tenets of the Declaration of Helsinki. All patients underwent 25-G+ vitrectomy. All vitrectomies were performed by a single surgeon (SG). Eyes with proliferative vitreoretinopathy grade C2 or worse or other retinal pathologies (macular hole, diabetic retinopathy, vein occlusion) were excluded from the study. All patients provided a written consent form before surgery to be included in the study.

All vitrectomies were performed using the 25-G+ Constellation Vitrectomy System (Alcon, Fort Worth, TX) and the Oculus BIOM non-contact, wide-angle viewing system (Oculus, Germany). Patients received retrobulbar local anesthesia with 2% lidocaine.

Three trocars were inserted at 3.5 mm or 4 mm from the limbus (depending on the lens status of the eye) inferotemporally, superonasally, and superotemporally. All eyes underwent pars plana vitrectomy with shaving of the vitreous base, especially at the place of the tears. No perfluorocarbon liquids were used and no drainage retinotomies were performed in any of the cases. Subretinal fluid was partially drained through the main break in some cases or was left completely in other cases with very peripheral breaks, even in bullous retinal detachments. Cryotherapy or endolaser photocoagulation was then performed to coagulate the breaks. At the end of the operation, 1 mL to 2 mL of pure SF6 gas were injected intraocularly to achieve a concentration of approximately 25% SF6 gas tamponade. The patients were instructed to stay at the side of the main break (for superior breaks, the patients were instructed to lie supine with a chin-up position, and for inferior breaks, they were instructed to stay upright. The previous statements have been added in the manuscript) for 1 hour, in order to assist the drainage of subretinal fluid through the break as the gas bubble was expanding. The patients were then strictly in face-down position in order to displace the fluid from the macular area. Face-down position was maintained for 45 to 50 minutes per hour for 2 weeks.

Main outcome measures were primary and final anatomical success rate; final postoperative visual acuity; and potential complications, either intraoperative or postoperative. All patients were examined at day 1, week 1, month 1, month 3, and month 6 after surgery. Visual acuity was measured using the Snellen chart and was then converted to logMAR. Student t test was used to compare pre- and postoperative (6 months' postoperative visit) best-corrected visual acuity (BCVA).

Results

One hundred eyes of 100 consecutive patients with primary rhegmatogenous retinal detachment were included to the study. Sixty-four percent were men and 36% were women. Mean age was 62.3 years ± 9 years. With regard to lens status, 56% of patients were phakic, and 44% pseudophakic.

Fifty-six percent of retinal detachments were macula-on and 44% were macula-off. Regarding the extent of the retinal detachment, only one quadrant was involved in 21% of patients, two quadrants were involved in 42%, the retinal detachment was extended in three quadrants in 29%, and all four quadrants were detached in 8% of patients.

Primary anatomical success rate was 94%, and the final success rate was 100%. Mean preoperative visual acuity was 0.75 logMAR, and mean postoperative visual acuity was 0.39 logMAR (P < .001).

Of the 56 eyes with macula on retinal detachment, seven lost VA at 6 months' postoperatively. Two showed decreased VA due to cataract and five showed decreased VA due to development of epiretinal membrane.

Remaining subretinal fluid at the end of the operation was recorded in 89% of patients. However, at the day 1 postoperative examination, there was no SRF present in any of the patients.

Early postoperative hypotony was observed in 8% of patients. Ten percent of patients showed postoperative hypertony, which was treated successfully with topical medication. No other peri- or postoperative complications were recorded.

Discussion

This study shows that drainage of subretinal fluid during vitrectomy for the treatment of a primary rhegmatogenous retinal detachment is not necessary in order to achieve a good anatomical and functional outcome. Our primary success rate was consistent with other case studies of small-gauge vitrectomy, where either perfluorocarbon liquid was used or a posterior retinotomy was performed for the drainage of subretinal fluid.6,7 BCVA was also improved postoperatively, despite the presence of submacular fluid in the macula-off cases. Moreover, avoiding the complete drainage of the subretinal fluid reduces the chance of intraoperative complications.

The use of perfluorocarbon stabilizes the retina and facilitates the trimming of the vitreous base, apart from displacing the subretinal fluid. However, it has been associated with postoperative inflammation and secondary glaucoma, especially when retained droplets remain postoperatively.8,9 Occasionally droplets of perfluorocarbon can be displaced subretinally, causing potential toxicity.10 Additionally, if the perfluorocarbon droplet is displaced subfoveally, it seriously affects the visual acuity and is extremely difficult to be removed.

Posterior retinotomy facilitates the drainage of subretinal fluid, thus helping the direct reattachment of the detached retina. However, it has been associated with subretinal neovascularization and visual field defects.11 We believe that this extra surgical maneuver can be avoided. Residual subretinal fluid is fully absorbed by the RPE pump, provided that the retinal breaks are sealed and attached to the RPE after cryopexy or laser photocoagulation.

Retinal folds are a potential complication — caused by the presence of persistent subretinal fluid, leading to postoperative metamorphopsia and decreased vision — when involving the macula. However, in the authors' case series, no case of postoperative retinal fold was recorded. We believe that strict and meticulous head-posturing immediately after surgery is of vital importance. All our patients were instructed to remain on the side of the main break for 1 hour at the end of the operation to facilitate the drainage of the subretinal fluid through the break. Then they were instructed to perform a face-down position, allowing the subretinal fluid to be displaced from the macula.

This is, to our knowledge, the first case series of treating primary rhegmatogenous retinal detachment with 25-G vitrectomy without drainage of the subretinal fluid. Yamaguchi et al. have reported similar results with 23-G vitrectomy and partial drainage of subretinal fluid through the main break.12

In conclusion, we believe that primary rhegmatogenous retinal detachment can be successfully treated without drainage of the subretinal fluid, without the use of perfluorocarbon liquid, and without performing drainage retinotomies. We can achieve similar anatomical and functional outcomes only by sealing the retinal breaks, tamponading the retina, and posturing the patients accordingly. In the era of small-gauge vitrectomy, reducing the surgical maneuvers and, thus, intraoperative complications seems to be safe and efficient.

References

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Authors

From the Athens Retina Institute, Athens, Greece (SG, EL); and the 1st Department of Ophthalmology, G. Genimatas University Hospital, Athens, Greece (PP, IG).

The authors report no relevant financial disclosures.

Address correspondence to Petros Petrou, MD, G. Gennimatas Hospital, Leoforos Mesogion 154, Athina 115 27; 30-21-0776-8000; email: petrospetrou2@yahoo.com.

Received: November 03, 2015
Accepted: February 29, 2016

10.3928/23258160-20160324-05

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