Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

PPV, Retinectomy, and Silicone Oil Without Scleral Buckle for Recurrent RRD From Proliferative Vitreoretinopathy

Jordan D. Deaner, MD; Christopher M. Aderman, MD; Lucas Bonafede, MD; Carl D. Regillo, MD

Abstract

BACKGROUND AND OBJECTIVE:

To analyze the anatomic success rate of pars plana vitrectomy (PPV), retinectomy, and silicone oil (SO) tamponade without scleral buckle (SB) for repair of recurrent rhegmatogenous retinal detachment (RRD) associated with proliferative vitreoretinopathy (PVR).

PATIENTS AND METHODS:

Retrospective, consecutive, single-surgeon case series of 28 eyes of 28 patients with PVR-associated RRD repaired with PPV, retinectomy, and SO tamponade without SB.

RESULTS:

The single-procedure anatomic success rate was 85.2% at 3 months and 82.1% at 12 months. Final reattachment rate was 100.0%. There were no preoperative factors that predicted single procedure anatomic success. Mean logarithm of the minimal angle of resolution visual acuity (VA) was improved at 3 months (1.61 to 1.51, P = .732) and at 12 months (1.61 to 1.41; P = .271). VA outcome was related to preoperative macula and lens status.

CONCLUSION:

The single-procedure anatomic success rate of PPV, retinectomy, and SO tamponade without SB for PVR-related recurrent RRD is comparable to prior reports of similar surgery incorporating SB.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:e278–e287.]

Abstract

BACKGROUND AND OBJECTIVE:

To analyze the anatomic success rate of pars plana vitrectomy (PPV), retinectomy, and silicone oil (SO) tamponade without scleral buckle (SB) for repair of recurrent rhegmatogenous retinal detachment (RRD) associated with proliferative vitreoretinopathy (PVR).

PATIENTS AND METHODS:

Retrospective, consecutive, single-surgeon case series of 28 eyes of 28 patients with PVR-associated RRD repaired with PPV, retinectomy, and SO tamponade without SB.

RESULTS:

The single-procedure anatomic success rate was 85.2% at 3 months and 82.1% at 12 months. Final reattachment rate was 100.0%. There were no preoperative factors that predicted single procedure anatomic success. Mean logarithm of the minimal angle of resolution visual acuity (VA) was improved at 3 months (1.61 to 1.51, P = .732) and at 12 months (1.61 to 1.41; P = .271). VA outcome was related to preoperative macula and lens status.

CONCLUSION:

The single-procedure anatomic success rate of PPV, retinectomy, and SO tamponade without SB for PVR-related recurrent RRD is comparable to prior reports of similar surgery incorporating SB.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:e278–e287.]

Introduction

Proliferative vitreoretinopathy (PVR) remains a serious complication in the surgical management of rhegmatogenous retinal detachments (RRDs). The risk of PVR after primary RRD surgical repair is noted to be from 5% to 10% and accounts for approximately 75% of all initial repair failures.1 The pathogenesis of PVR is not fully understood, but it has been a topic of extensive investigation.2–5 Currently, there is no consensus on the best approach when it comes to the surgical management of recurrent RRD from PVR.6

Pars plana vitrectomy (PPV) with relaxing retinectomy and silicone oil (SO), alone or in combination with a scleral buckle (SB), is typically utilized for repair of recurrent RRD associated with significant PVR. The reported overall single-procedure anatomic success rate of RRD with PVR is between 47% to 85%.7–9 Most published reports with surgeries requiring retinectomy and oil in this setting use various techniques in which SB is inconsistently present or utilized. One of the largest and most recent reports on this topic by Tan et al. showed relatively high rates of single-procedure success (77.2%) with PPV, retinectomy, and SO without SB.10

It is difficult to draw conclusions on the best surgical approach to PVR-RRD because much of what has been published utilizes multiple surgeons with multiple approaches over a long-time frame. Based on the authors' experience and the latest published literature, adding a SB in PVR cases in which inferior retinectomy and oil is used may not be necessary. The aim of our study is to present the single-surgeon success rate of PPV, retinectomy, and SO without the addition of (or history of) a SB in the treatment of PVR after RRD to determine if this approach can achieve similar or better rates of single-surgery success compared to prior published reports of PVR-RRD cases with retinectomy and oil use in which a SB is present.

Patients and Methods

The study was approved by the institutional review board of Wills Eye Hospital and was completed in accordance to the Declaration of Helsinki. Our study is a retrospective review of all patient charts who underwent PPV, retinectomy, and SO without SB by a single surgeon (CDR) for PVR-related recurrent retinal detachment between January 1, 2012, and January 1, 2017 (Figure 1). A single surgeon was used to control for surgeon variations in technique. Excluded were eyes with prior SBs and history of infectious or inflammatory uveitis and vasoproliferative disease. Of note, eyes with a history of penetrating trauma were included in this series in order to not bias the series to less-severe PVR cases.

Patient selection. SO = silicone oil; SB = scleral buckle; PPV = pars plana vitrectomy; PVR = proliferative vitreoretinopathy; RD = retinal detachment; TRD = total retinal detachment; RRD = rhegmatogenous retinal detachment; FEVR = familial exudative vitreoretinopathy

Figure 1.

Patient selection. SO = silicone oil; SB = scleral buckle; PPV = pars plana vitrectomy; PVR = proliferative vitreoretinopathy; RD = retinal detachment; TRD = total retinal detachment; RRD = rhegmatogenous retinal detachment; FEVR = familial exudative vitreoretinopathy

A standard three-port 23-gauge PPV approach was used in all cases. All operations were performed on the Alcon Accurus or Constellation (Alcon Laboratories, Fort Worth, TX), with one of several non-contact widefield viewing systems for visualization.

Triamcinolone acetonide suspension or indocyanine green (ICG) staining were used when necessary to help identify or assist in removal of pre-retinal membranes with forceps. A retinectomy positioned typically inferiorly just posterior to the posterior vitreous base insertion was performed using the vitreous cutter to address residual retinal foreshortening after peeling of pre-retinal membranes. The retinectomy included all retina anterior to the initial cut to the pars plana. Lensectomy was not routinely performed in phakic eyes and done only if necessary due to severe opacification obstructing the surgeon's view of the posterior segment. Perfluorocarbon liquid was then used to entirely flatten the retina. Laser retinopexy was applied in a confluent two- to three-row fashion along the retinectomy edge and around any other breaks, and 1,000 cs SO was infused after a perfluorocarbon-air fluid exchange. Patients positioned with their head upright during the day and approximately 45° at night for 5 to 7 days after surgery. No face-down positioning was utilized postoperatively.

Preoperative data collected from the charts included patient age, gender, visual acuity (VA), intraocular pressure (IOP), macula status (on or off), location and extent of PVR, lens status, prior surgical procedures, and original diagnosis. VAs were recorded as best-available Snellen VA measurements then converted to their equivalent logarithm of the minimal angle of resolution (logMAR) values for analysis. Data obtained from the operative reports included exact extent and location of retinectomy and any surgical complications. Postoperative data included VA, IOP, anatomic success (defined as complete retinal attachment), complications, presence of SO, and need for further surgery at the 1-, 3-, 6-, and 12-month visits. The primary outcome was single-procedure anatomic success at 3 months. Other outcome measures included the rate of complete attachment at 12 months, number of operative procedures after the initial procedure, presence of SO, rate of postoperative hypotony (< 6 mm Hg) and hypertension (> 25 mm Hg).

All statistical analyses were performed using SPSS 25 (SPSS Inc., Chicago, IL). Statistical significance was determined using Mann-Whitney U, Kruskal-Wallis, Wilcoxon signed-rank test, and Pearson Chi-square testing as appropriate. Statistical significance was defined as P values less than .05.

Results

A total of 28 eyes from 28 patients were included. Mean follow-up was 12 months (range: 8 months to 13 months). Baseline ocular and patient characteristics are summarized in Table 1. The mean age was 58 years (range: 17 years to 91 years). Preoperatively, 26 eyes (92.9%) had subretinal fluid under the macula and four (14.3%) had VA that was better than 20/200. Most eyes (26; 92.9%) had undergone a previous PPV (mean: 1.21; range: 0 to 3), and a single eye underwent a pneumatic retinopexy for previous RRD. The other two eyes had chronic RRD that developed subsequent PVR. Three eyes (10.7%) had prior ruptured globes requiring rupture globe repair in one case and repeat penetrating keratoplasty in the other two cases prior to RRD repair. There were no intraoperative complications. No cases of endophthalmitis or sympathetic ophthalmia were encountered.

Patient Characteristics (n = 28)

Table 1:

Patient Characteristics (n = 28)

The single-procedure anatomic success at 3 months was 85.2% (Table 2). All eyes remained under SO tamponade at the primary endpoint. Two eyes developed retinal detachments by 1-month follow-up and another two eyes developed detachments by 3-month follow-up, an average of 42 days to detachment overall. All four failures were the result of recurrent proliferation and were repaired with PPV, additional membrane dissection, and extension of the retinectomy followed with repeat SO tamponade. Of these failures, two eyes required a single additional procedure to completely reattach the retina, and two eyes required two additional procedures. There were no preoperative factors that had a statistically significant effect on anatomic outcome at 3 months (Table 3). There was a trend toward improved mean logMAR VA (Snellen VA) at 3-month follow-up from 1.61 ± 0.67 (20/815) preoperatively to 1.51 ± 0.63 (20/647) (Wilcoxon Ranked-Sum, P = .732). The only preoperative factor found to be associated with improved VA outcome at 3-months was the macula status (Mann-Whitney U Test, P = .01) (Table 4). One of the failures also developed ocular hypertension with a maximum IOP of 32 mm Hg, controlled with topical antihypertensives. No eyes were complicated by hypotony. Eyes with larger retinectomies (±6 clock hours) had on average lower IOP (13.79 mm Hg ± 4.49 mm Hg) compared to eyes with smaller retinectomies (15.23 mm Hg ± 4.27 mm Hg), but this was not statistically significant (Mann-Whitney U Test, P = .512).

Outcomes at 3 Months (n = 27)

Table 2:

Outcomes at 3 Months (n = 27)

Predicting Primary Anatomic Success at 3 Months (n = 27)

Table 3:

Predicting Primary Anatomic Success at 3 Months (n = 27)

Predicting Visual Acuity at 3 Months (n = 27)

Table 4:

Predicting Visual Acuity at 3 Months (n = 27)

At 12 months, single-procedure anatomic success was 82.1% (Table 5). An additional failure occurred due to recurrent proliferation 131 days after initial retinectomy, 98 days after planned SO removal, and required one additional operation to completely reattached the retina. The overall average time to failure lengthened to 60 days. A final retinal reattachment rate was achieved in 100% of cases requiring an average of 1.25 surgeries overall.

Final Outcomes (n = 28)

Table 5:

Final Outcomes (n = 28)

SO removal was attempted in 17 of the 24 (70.8%) initially successful eyes. The average time to SO removal was 157 days. One eye (4.1%) went on to develop recurrent proliferation after SO removal. Of the 23 eyes with single-procedure success at 12 months, 16 (69.6%) remained successfully attached after SO removal. SO remained in seven (30.4%) of the eyes with single-procedure success. Notably, two of these eyes were complicated ruptured globes, one was lost to follow-up for 11 months after surgery, and one was complicated by progression of proliferative diabetic retinopathy. The remaining three eyes (13.0%) had a poor visual prognosis, were deemed high risk for redetachment, and were tolerating the SO without complications.

There were no preoperative factors that had a statistically significant association with anatomic outcome at 12 months (Table 6). There was a trend toward improved mean logMAR VA (Snellen VA) at 12-month follow-up from 1.61 ± 0.67 (20/815) preoperatively to 1.41 ± 0.79 (20/514), but this was not statistically significant (Wilcoxon Ranked-Sum, P = .271). The only preoperative factor found to affect VA at 12-months was the lens status, with patients who were pseudophakic preoperatively having better visual outcomes than aphakic and phakic patients (Kruskal-Wallis Test, P < .01) (Table 7). The phakic subgroup trended toward improvement in VA with logMAR VA (Snellen VA) of 1.53 ± 0.78 (20/678) at 12 months from 1.75 ± 0.63 (20/1125) at baseline (Wilcoxon Ranked-Sum, P = .305). The logMAR VA (Snellen VA) of the pseudophakic subgroup improved at 12 months to 0.92 ± 0.65 (20/166) from 1.23 ± 0.73 (20/340) at baseline (Wilcoxon Ranked-Sum, P = .398). The aphakic subgroup VA declined from baseline at postoperative month 12 to 2.21 ± 0.15 (20/3,244) from 2.06 ± 0.15 (20/2,296) at baseline (Wilcoxon Ranked-Sum, P = .317).

Predicting Final Primary Anatomic Success (n = 28)

Table 6:

Predicting Final Primary Anatomic Success (n = 28)

Predicting Final Visual Acuity (n = 28)

Table 7:

Predicting Final Visual Acuity (n = 28)

An additional eye developed ocular hypertension (IOP = 30 mm Hg) by 12 months requiring a tube shunt operation for IOP control. There were no cases complicated by hypotony by 12 months. Again at 12 months, eyes with larger retinectomies (±6 clock hours) had on average lower IOP (12.38 mm Hg ± 5.59 mm Hg) compared to eyes with smaller retinectomies (14.69 mm Hg ± 5.02 mm Hg), but this was not statistically significant (Mann-Whitney U Test, P = .938).

Discussion

Retinectomy is often necessary, albeit a last resort, in the management of complex retinal detachment with severe PVR when retinal traction remains despite peeling of preretinal and/or subretinal membranes. We describe a series of patients who underwent PPV, retinectomy, and SO without SB by a single surgeon. Our single-operation success rate was 85.2% at 3 months and 82.1% at 12 months after factoring in attempted SO removal in most eyes. Recurrent PVR was determined to be the cause of failure with the need for additional surgery in all eyes. Of the failures, it took an average of 1.4 additional operations to achieve complete retinal reattachment in all eyes. It is important to note that approximately 40% of eyes did not undergo SO removal. Long-term follow-up with SO removal will be required to evaluate long-lasting success.

Previous studies of PPV with retinectomy surgery with and without the presence or addition of a SB for PVR-related RRD show single-procedure success rates to be between 47% and 85%.10–16 Comparisons between these studies are difficult as inclusion criteria differ along with the surgical approach. In our study, no eyes that had a SB placed before the PVR-associated RRD were included and SB were not placed during or after the initial PPV, retinectomy, and SO surgery. Our single-surgery success rate is on the high end of that published in the literature using PPV/retinectomy and oil, including many cases having a SB present before or at the time of final surgery.

There was no significant association between clock-hour extent of retinectomy and anatomic success. A review of the literature finds a similar lack of association.10,11,13,15,17 There were no other preoperative factors that had a statistically significant association with anatomic success at 3 months or 12 months.

There was an average change in logMAR VA (Snellen VA) from 1.61 (20/815) preoperatively to 1.51 (20/647) at 3 months and 1.41 (20/514) at 12 months; however, this was not statistically significant (P = .732 and P = .271, respectively). Prior studies have defined functional success at a final VA of 20/800 or better (logMAR < 1.6) with success rates reported between 26% and 67.3%.10,15,17–19 By these definitions, our functional success is 55.6% at 3 months and 50.0% at 12 months.

Improved VA (logMAR, Snellen) at 3 months was associated with preoperative macula status, with macula-on detachments achieving a better mean VA (0.40, 20/50) at 3 months compared to the macula-off eyes (1.62, 20/834, P = .014). Many previous studies have found an indirect association between increasing extent of retinectomy and worse VA.10,11,15,20,21 We found a trend toward worse VA at 3 and 12 months with larger retinectomies (> 6 clock hours); however, this did not reach statistical significance (P = .179, P = .182, respectively). This is likely due our study being underpowered by its small sample size. There was no significant association between preoperative VA or primary success and visual outcomes at 3 or 12 months. Improved logMAR VA at 12 months was associated with preoperative pseudophakic lens status compare to phakic or aphakic patients, despite all phakic patients undergoing cataract extraction by final follow-up.

Tan et al.10 reports leaving SO chronically in 21.1% of eyes in their series. In our study, SO remained in 11 eyes (39.3%). Notably, SO was left in seven eyes with single-procedure success, and these were eyes that had a very poor visual prognosis or were deemed high risk for recurrent detachment with SO removal. Of the five primary failures, four occurred under SO tamponade within the first 3 months. The fifth occurred 5 months after the initial retinectomy, 2 months after planned SO removal.

SO has been associated with complications including cataract, elevated IOP, and emulsification.22 Ocular hypertension from SO instillation and hypotony from retinectomy are potentially vision- and eye-threatening complications in the setting of PVR surgery. An extensive meta-analysis reports that the risk of ocular hypertension after SO tamponade ranges 0% to 56% during a follow-up range of 3 months to 23 years.23 The etiology of ocular hypertension after SO fill is multifactorial.23 Only one eye developed ocular hypertension (IOP: 32 mm Hg) by our primary endpoint of 3 months, which was effectively treated with topical antihypertensive drops. Of note this eye had recurrent PVR-related detachment 44 days after initial surgery and required repeat PPV, retinectomy extension, and SO exchange. An additional single-procedure success eye developed ocular hypertension at 6-month follow-up and underwent SO removal and tube shunt 203 days after initial PPV with retinectomy. Of note, our incidence of ocular hypertension related to chronic SO presence is likely attenuated given our follow-up duration limited to 12 months. There were no cases of SO emulsification in our series.

There were no incidences of ocular hypotony in our study, either by IOP cutoff (IOP < 6 mm Hg) or by clinical signs of hypotony (presence of Descemet folds, choroidal folds, or optic nerve edema). Previous studies found the risk of ocular hypotony after PPV with retinectomy ranges from 4.1% to 39%.10,12–14,17,21,24–27 The etiology of hypotony after PPV with retinectomy for PVR is not fully understood and likely also multifactorial with one potential contributing factor being residual anterior retina in the clock hours of the retinectomy.27

By design, this is a single-surgeon study aiming to minimize inter-surgeon technique variables by using the same surgical approach and equipment on all patients. We acknowledge that there are limitations to the study. By analyzing the results of one surgeon, the series is relatively small, and the outcomes may not be generalizable. Furthermore, the retrospective and non-randomized nature of this study limits comparisons to other studies and techniques.

In conclusion, our results show that PPV, retinectomy, and SO tamponade without SB has a single-procedure success rate similar to or better than what has been reported when a similar surgical approach is combined with SB based on previously published reports. Adding a SB when a relatively large inferior retinectomy is being performed and SO tamponade is utilized may not be necessary or useful in the augmenting initial or final retinal reattachment rates. Rather, placing a SB adds potential operative time, cost, and morbidity to the vitrectomy.

References

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Patient Characteristics (n = 28)

Mean Age, Years (Range)58(17 to 91)
Gender
  Male16(57.1%)
  Female12(42.9%)

Surgical Eye
  Right15(53.6%)
  Left13(46.4%)

Macula Status
  On2(7.1%)
  Off26(92.9%)

Baseline VA
  Mean, LogMAR (Snellen)1.61(20/800)
  Better than 20/2004(14.3%)
  CF to 20/20018(64.3%)
  Worse than CF6(21.4%)

Prior Vitreous Surgery
  02(7.1%)
  126(92.9%)

Lens Status
  Phakic14(50.0%)
  Pseudophakic10(35.7%)
  Aphakic4(14.3%)

Outcomes at 3 Months (n = 27)

Single-Procedure Success23(85.2%)
  SO out0(0.0%)
  SO in27(100.0%)

Number of Reoperations Required
  023(85.2%)
  12(7.4%)
  22(7.4%)

Visual Acuity
  Mean, LogMAR (Snellen)1.51(20/630)
  Better than 20/2004(14.8%)
  CF to 20/20021(77.8%)
  Worse than CF2(7.4%)

Postoperative IOP Complications
  Ocular Hypertension (IOP > 25)1(3.7%)
  Ocular Hypotony (IOP < 5)0(0.0%)

Predicting Primary Anatomic Success at 3 Months (n = 27)

Success (n = 23)Failure (n = 4)P Value

Mean Age, Years5859.918a

Mean Baseline VA, logMAR (Snellen)1.58(20/800)1.81(20/1600).912a

Gender0.683b
  Male14(60.9%)2(50.0%)
  Female9(39.1%)2(50.0%)

Surgical Eye.396b
  Right12(52.2%)3(75.0%)
  Left11(47.8%)1(25.0%)

Macula Status.540b
  On2(8.7%)0(0.0%)
  Off23(91.3%)4(100.0%)

Lens Status.587b
  Phakic12(52.2%)1(25.0%)
  Pseudophakic8(34.8%)2(50.0%)
  Aphakic3(13.0%)1(25.0%)

Retinectomy Extent, Clock Hours.936b
  < 611(47.8%)2(50.0%)
  ≥ to 612(52.2%)2(50.0%)

Predicting Visual Acuity at 3 Months (n = 27)

Mean logMAR VAP Value

Age, Years.430a
  < 60 (n=11)1.41
  60 or older (n=16)1.62

Gender0.156a
  Male (n = 16)1.38
  Female (n = 11)1.77

Surgical Eye.132a
  Right (n = 15)1.41
  Left (n = 12)1.70

Macula Status.014a
  On (n = 2)0.42
  Off (n = 25)1.62

Lens Status.113b
  Phakic (n = 13)1.50
  Pseudophakic (n = 10)1.38
  Aphakic (n = 4)2.06

Retinectomy Extent, Clock Hours.179a
  < 6 (n = 13)1.39
  ≥ 6 (n=14)1.67

Preoperative VA.594a
  CF or better (n = 19)1.50
  Worse than CF (n = 5)1.72

Primary Success.561a
  Yes (n = 23)1.50
  No (n = 4)1.74

Final Outcomes (n = 28)

Mean Last Follow-Up, Days374

Single-Procedure Success23(82.1%)
  SO out16(69.6%)
  SO in7(30.4%)

Final Success28(100.0%)
  SO out17(60.7%)
  SO in11(39.3%)

Number of Reoperations Required
  023(82.1%)
  13(10.7%)
  22(7.1%)

Final Failure0(0.0%)

Final Visual Acuity
  Mean, logMAR (Snellen)1.41(20/500)
  Better than 20/2008(28.6%)
  CF to 20/20014(50.0%)
  Worse than CF6(21.4%)

Postoperative IOP Complications
  Ocular hypertension (IOP > 25)2(7.1%)
  Ocular hypotony (IOP < 5)0(0.0%)

Lens Status
  Phakic0(0.0%)
  Pseudophakic22(78.6%)
  Aphakic6(21.4%)

Predicting Final Primary Anatomic Success (n = 28)

Success (n = 23)Failure (n = 5)P Value

Mean Age, Years5861.435a

Mean Baseline VA, logMAR (Snellen)1.54(20/630)1.92(CF).846a

Gender.393b
  Male14(60.9%)2(40.0%)
  Female9(39.1%)3(60.0%)

Surgical Eye.750b
  Right12(52.2%)3(60.0%)
  Left11(47.8%)2(40.0%)

Macula Status.494b
  On2(8.7%)0(0.0%)
  Off21(91.3%)5(100.0%)

Lens Status.864b
  Phakic12(52.2%)2(40.0%)
  Pseudophakic8(34.8%)2(40.0%)
  Aphakic3(13.0%)1(20.0%)

Retinectomy Extent, Clock Hours.662b
  < 612(52.2%)2(40.0%)
  ≥ 611(47.8%)3(60.0%)

Predicting Final Visual Acuity (n = 28)

Mean logMAR VAP Value

Age, Years.962a
  < 60 (n = 12)1.37
  60 or older (n = 16)1.44

Gender.906a
  Male (n = 16)1.34
  Female (n = 12)1.50

Surgical Eye.439a
  Right (n = 15)1.36
  Left (n = 13)1.46

Macula Status.093a
  On (n = 2)0.50
  Off (n = 26)1.48

Lens Status.009b
  Phakic (n = 14)1.53
  Pseudophakic (n = 10)0.92
  Aphakic (n = 4)2.21

Retinectomy Extent, Clock Hours.182a
  < 6 (n = 14)1.21
  ≥ 6 (n = 14)1.61

Preoperative VA.270a
  CF or better (n = 19)1.30
  Worse than CF (n = 6)1.87

Primary Success.737a
  Yes (n = 23)1.36
  No (n = 5)1.64
Authors

From Retina Service, Wills Eye Hospital, Philadelphia.

The authors report no relevant financial disclosures.

Address correspondence to Carl D. Regillo, MD, Retina Service, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107; email: cregillo@midatlanticretina.com.

Received: September 24, 2018
Accepted: March 22, 2019

10.3928/23258160-20191031-15

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