The use of pars plana vitrectomy (PPV) alone with gas tamponade for the surgical repair of rhegmatogenous retinal detachment (RRD) has become increasingly common, with technological advances, including widefield viewing systems, helping to improve outcomes. It is an especially successful technique for RRD caused by superior and midline breaks.1–3 Surgical adjuvants including concurrent scleral buckle (SB), silicone oil (SO), and 360° laser, however, are often utilized for more complex cases.1,4
Primary RRD with inferior breaks can be challenging, especially in phakic patients, and for which PPV is often combined with encircling SB. There is concern with PPV alone regarding access to the inferior vitreous base and tears in the phakic state to relieve all traction and obtaining adequate postoperative tamponade of inferior breaks. However, the necessity of a SB in addition to PPV has been questioned. There are added issues with performing a concurrent SB including postoperative pain, induced myopia, and operative time. Adding a SB is also not free of risk and can include perforation, choroidal hemorrhage, diplopia, infection, ischemic, and explant erosion or infection.5–9
Expanding published literature suggests that concurrent SB for primary RRD with inferior breaks may not provide any statistically significant benefit in single-surgery success.1,4,10–15 Some studies have identified the presence of an inferior break as a risk factor for failure.16 Many of these studies, however, include a mix of phakic and pseudophakic eyes.1,4,10–16 They also group patients together with primary RRD that include inferior breaks with those that are caused by or limited to inferior breaks. The published studies that examine success rates of primary RRDs caused by inferior breaks alone are in pseudophakic eyes.17–19
Therefore, the literature is limited on the topic of PPV without SB in phakic eyes with primary RRD caused by inferior breaks. This study examines whether PPV without SB can achieve a high rate of reattachment in primary RRD caused by inferior retinal breaks in phakic eyes.
Patients and Methods
We retrospectively reviewed the medical records of surgeries by CDR between January 1, 2012, and December 31, 2016, at Mid-Atlantic Retina / Wills Eye Hospital. Patients with primary, phakic RRD with inferior flap breaks and a posterior vitreous detachment (PVD) repaired by pars plana vitrectomy (PPV), endolaser, and gas tamponade were included in this consecutive, single-surgeon series. Causative breaks were defined as those occurring between 4-o'clock and 8-o'clock within the detached retina and determined responsible for the RRD. It was the surgeon's routine over this study time frame to repair PVD-related primary RRD with PPV alone and non-PVD detachments with SB alone, but not to combine PPV with SB for any primary PPV. Patients with prior retinal surgery including PPV, SB, and pneumatic retinopexy were excluded. Patients with proliferative vitreoretinopathy (PVR) were excluded. The study was approved by the institutional review board, was HIPAA-compliant, and all the study procedures adhered to the tenets of the Declaration of Helsinki.
All surgeries were performed by CDR according to his usual standard of practice. Sclerotomy cannulas were typically placed near the horizontal meridian to help access the inferior vitreous base and breaks. Complete vitrectomy with scleral depression was performed via non-contact widefield viewing. All breaks were marked with diathermy. Primary breaks were enlarged anteriorly to relieve traction on the break and maximize drainage. A complete fluid-air exchange was performed. The technique for drainage of subretinal fluid (SRF) varied by case and included direct extrusion of SRF through the pre-existing break(s), posterior retinotomy, and through pre-existing break(s) via perfluorocarbon liquid. All breaks / lattice degeneration / suspicious areas were surrounded by laser; 360° laser or scatter laser were not performed. The air, in turn, was exchanged with either 20% sulfahexafluoride (SF6) or 12% perfluoropropane (C3F8) gas.
Outcomes Measures and Statistical Analysis
The main outcome measure for this study was single-surgery success rate at postoperative month (POM) 3. Secondary outcomes included 12-month single-surgery success rate, final reattachment success rate, final postoperative visual acuity (VA) and factors associated with initial surgical failure.
Data analysis was performed using SPSS version 24 (SPSS, Chicago, IL). Before and after measurements of continuous variables were evaluated using the paired t-test. Comparison of continuous variables between independent categories were evaluated using the independent t-test.
Twenty-six eyes from 26 patients met study criteria and underwent primary PPV alone for RRD with causative inferior breaks. The mean age of the patients at the time of repair was 61.7 years (range: 38 years to 82 years), with 16 (62%) of the patients being male. Thirteen cases of RRD were macula-involving (50%), with an mean (± standard deviation) of 2.00 ± 0.70 involved quadrants and 2.50 ± 2.00 breaks within the detachment. Twenty-three eyes (88.5%) had C3F8 gas tamponade and the remaining three eyes (11.5%) had SF6 gas tamponade (Table 1). Mean follow-up was 15.9 months (range: 3 months to 42 months). No intraoperative complications or surgical adverse events were noted. Twenty-three of 26 eyes (88.5%) remained attached at postoperative month (POM) 3 after one surgery. Thirteen of 16 eyes (81.3%) remained attached at POM 12 after one surgery.
Baseline Clinical Characteristics of Phakic Patients Who Underwent Vitrectomy Alone for Primary RRDs Associated With Inferior Breaks, N (%) or Mean (± SD)
Of the three patients who detached, one had a giant retinal tear (GRT) that opened and two developed PVR. The first patient was a 38-year-old man who presented with a macula-sparing RRD (PVD present) with an inferior GRT associated with three quadrants of SRF. SRF was drained with perfluorocarbon and C3F8 gas was used. At POM 2, the GRT reopened and the patient underwent another PPV with SO instillation, which was successful, and sustained complete retinal reattachment after SO removal several months later. The second patient was a 67-year-old woman who presented with a two-quadrant and macula-involving RRD with a single tear inferiorly. After PPV with C3F8 tamponade, the patient re-detached with PVR at POM 1 and underwent an inferior retinectomy with SO tamponade. The patient re-detached again 1 month later and underwent membrane peeling for PVR with SO exchange. Six months from the initial surgery, however, the patient sustained complete reattachment after SO removal. The last patient was a 64-year-old man who also presented with a two-quadrant macula-involving RRD with a single tear inferiorly. After PPV with C3F8 tamponade, the patient re-detached with PVR at 3 weeks and underwent a PPV with SB and SO instillation without further redetachment. SO was successfully removed without redetachment 6 months after the initial surgery.
Mean logMAR VA was 0.72 ± 0.84 at baseline, 0.65 ± 0.44 at POM 3, 0.52 ± 0.45 at POM 6, 0.44 ± 0.50 at POM 12, and 0.43 ± 0.36 at the final visit (P = .12) (Figure 1). 4% of eyes had cataract surgery by POM 3, 38% by POM 6, and 91% by POM 12. 92% of eyes had cataract surgery by the final visit. Patients with macula-sparing RRDs had significantly better logMAR VA at the final visit (mean: 0.29 ± 0.30) compared to those with macula-involving RRDs (mean: 0.57 ± 0.37; P = .046). There was a mean improvement from the preoperative visit compared to the final visit in logMAR VA of 0.04 ± 0.66 in the macula-sparing RRD compared with 0.52 ± 1.02 in the macular-involving RRD patients. This difference with regarding to macula status, however, was not significant (P = .19).
Boxplot graph of logMAR visual acuity (VA) at baseline, postoperative, and final visits. Inside each box, the central line represents the median, and the diamonds represent the mean. The twenty-fifth and the seventy-fifth percentile are represented by the bottom and top borders of the box, respectively. The bottom and upper whiskers represent the minimum and maximum values, respectively. Circles outside of the whiskers represent the outliers.
To the best of our knowledge, this is the first and largest series to examine whether phakic RRD caused by inferior breaks can be repaired by PPV alone (ie, without SB) and still achieve a high rate of success. We found that 88.5% of eyes were fully attached at POM 3 with a single surgery, and all of these eyes remained attached until the final visit with a mean of 16 months.
Although still limited, there has been a growing number of published series on the outcomes of vitrectomy and gas alone (without scleral buckles) focusing on retinal break location. Several studies examined retinal detachments outcomes in patients with inferior breaks (rather than specifying causative breaks) and often include mainly pseudophakic patients. Schneider et al. published a large series of 93 eyes that had PPV alone with gas tamponade for primary RRD and found a 95.7% single-surgery success. They excluded those who had intraoperative perfluorocarbon, unlike our study. Their study, however, had a relative low percentage of patients with inferior breaks (35% of 40 phakic patients).1 Wickham et al. compared 86 patients with RRD including inferior breaks who had either PPV alone or PPV with SB finding a similar and high rate of reattachment (95% vs. 93%). Less than half of each group were phakic (18 phakic eyes had PPV alone).11 Additionally, Sharma et al. compared 48 eyes with RRD including inferior breaks treated with PPV alone to 48 eyes with RRD without inferior breaks finding no statistically significant difference between the groups but an overall lower rate of single surgery success (81.3% and 85.4%) than others. Thirty-six of their 48 eyes with inferior breaks were phakic, but the authors were clear in their paper that this group did not exclude those with superior causative breaks.13
Among those studies that analyzed PPV alone for RRD caused by inferior breaks, pseudophakic patients are more common. Martinez-Castillo et al. first published a smaller, 15-patient study of pseudophakic RRD with only inferior breaks who underwent PPV alone with air tamponade, finding a single-surgery success rate of 93.3%.17 Their larger series of 147 pseudophakic patients with RRD with causative inferior breaks treated with PPV alone with gas tamponade found a similarly high single-surgery success rate (94.5%).19 For studies that looked at phakic RRD with causative inferior breaks, the results were mixed. For instance, Goto et al. compared PPV alone for RRD with causative superior and inferior breaks of 82 eyes. Only 20 of the 82 eyes were caused by inferior breaks, and they included both phakic and pseudophakic patients. They found lower rate of single-surgery success in the inferior group (80%; P = .012) but used 20% SF6 as the endotamponade agent for all cases.16 Finally, Stavrakas et al. compared 113 eyes with primary RRD caused by superior breaks to 40 eyes caused by inferior breaks and treated with PPV alone, finding no significant difference in single-surgery success rates. They did not specify how many of the inferior break patients were phakic but stated that less than half of the overall patients in the study were phakic.12
Our single-surgery success rate of 88.5% falls in line with the above studies, despite the fact that our paper included a uniform population of phakic RRD caused by inferior breaks. It might be that these two variables may lead to a slightly lower success rate (eg, 80% success rate in the Goto et al. publication) than a predominantly superior break population like the published report by Schneider et al., though not significantly different. It was previously thought that the addition of a SB to a PPV would help to further support inferior breaks in phakic eyes if unable to relieve traction or ensure adequate gas tamponade. With improved technology, including small-gauge transconjunctival systems and widefield viewing systems, relief of inferior vitreous traction can be achieved in these patients with scleral indentation and shaving. Positioning the sclerotomies close to the horizontal meridian allows for adequate access of the inferior vitreous base in phakic eyes without striking the lens, which did not happen in any eye in our series. Enlarging the breaks anteriorly may also help to ensure relieving traction at the break site in addition to augmenting SRF drainage and allowing for better intraocular gas fill.
The findings in this study do not suggest (nor are meant to imply) that SB alone does not have a role in the management of inferior RRD. In younger patients with primary RRD not associated with a PVD, SB alone (without PPV) remains the author's (CDR) procedure of choice. However, for primary RRD with a PVD, PPV alone has become the author's routine.
Three patients within our study re-detached, though it does not appear due to incomplete removal of vitreous traction. Two patients developed PVR without new breaks and went on to have repeat PPV with retinectomy and SO tamponade for repair of the subsequent complex retinal detachment. The third patient had postoperative reopening of an inferior GRT. This patient could have re-detached due to incomplete removal of gel or inadequate tamponade, but GRTs have a higher rate of redetachment compared to other retinal detachments. The value of encircling SB with PPV remains controversial in these high-risk GRT cases.20
Additionally, a potential confounder in our assessment of VA is the development of a cataract. All our patients were counseled preoperatively about accelerated cataract development following PPV as a known side effect. Cataract removal at the time of RRD repair is not typically performed by the authors unless it prevents adequate visualization and concurrent lens removal was not required in any of the cases in this series. Calculation of logMAR VA in this study revealed a slow and steady improvement through the final visit, more gradual than one would expect from RRD repair alone. This is likely due to cataract progression and then removal as 92% of eyes had cataract surgery before the final visit albeit not at a uniform time point. The logMAR VA improved from the POM 6 visit to the POM 12 visit, likely reflecting cataract progression and removal as only 38% of eyes had cataract surgery by the POM 6 visit, but 91% of eyes had cataract surgery by the POM 12 visit.
There are a number of limitations in this study, including its retrospective nature as well as the lack of a control group of pseudophakic RRD or RRD treated with combined procedure. Our series is small and prevented a more thorough analysis of risk factors for redetachment or VA outcomes. However, phakic RRD caused by inferior breaks are less common than those caused by superior breaks as is evidenced by several of the other studies cited in this paper.
In conclusion, our single-surgery reattachment success rate of eyes with phakic RRD associated with inferior breaks repaired by PPV alone is high and compares favorably with historic controls of similar cases repaired with PPV combined with SB along with other types of primary RRD, regardless of break location and phakic status. In this context, our study suggest that concurrent SB may be not be necessary on a routine basis for eyes undergoing PPV for primary RRD caused by inferior breaks in phakic eyes. A larger, controlled, prospective study would be necessary to better assess the exact comparative success rate of PPV with SB versus without SB for inferior primary RRD.
- Schneider EW, Geraets RL, Johnson MJ. Pars plana vitrectomy without adjuvant procedures for repair of primary rhegmatogenous retinal detachment. Retina. 2012;32(2):213–219. doi:10.1097/IAE.0b013e3182278b29 [CrossRef]
- Mendrinos E, Dang-Burgener NP, Stangos AN, Sommerhalder J, Pournaras CF. Primary vitrectomy without scleral buckling for pseudophakic rhegmatogenous retinal detachment. Am J Ophthalmol. 2008;145(6):1063–1070. doi:10.1016/j.ajo.2008.01.018 [CrossRef]
- Miller DM, Riemann CD, Foster RE, Petersen MR. Primary repair of retinal detachment with 25-gauge pars plana vitrectomy. Retina. 2008;28(7):931–936. doi:10.1097/IAE.0b013e31816b313a [CrossRef]
- Duvdevan N, Mimouni M, Feigin E, Barak Y. 25-gauge pars plana vitrectomy and SF6 gas for the repair of primary inferior rhegmatogenous retinal detachment. Retina. 2016;36(6):1064–1069. doi:10.1097/IAE.0000000000000853 [CrossRef]
- Flindall RJ, Norton EWD, Curtin VT, Gass JDM. Reduction of extrusion and infection following episcleral silicone implants and cryopexy in retinal detachment surgery. Am J Ophthalmol. 1971;71(4):835–837. doi:10.1016/0002-9394(71)90250-9 [CrossRef]
- Hayashi H, Hayashi K, Nakao F, Hayashi F. Corneal shape changes after scleral buckling surgery. Ophthalmology. 1997;104(5):831–837. doi:10.1016/S0161-6420(97)30226-7 [CrossRef]
- Domniz YY, Cahana M, Avni I. Corneal surface changes after pars plana vitrectomy and scleral buckling surgery. J Cataract Refract Surg. 2001;27(6):868–872. doi:10.1016/S0886-3350(00)00755-0 [CrossRef]
- Fison PN, Chignell AH. Diplopia after retinal detachment surgery. Br J Ophthalmol. 1987;71(7):521–525. doi:10.1136/bjo.71.7.521 [CrossRef]
- Kwartz J, Charles S, McCormack P, Jackson A, Lavin M. Anterior segment ischaemia following segmental scleral buckling. Br J Ophthalmol. 1994;78(5):409–410. doi:10.1136/bjo.78.5.409 [CrossRef]
- Zhou C, Qiu Q, Zhen Z. Air versus gas tamponade in rhegmatogenous retinal detachment with inferior breaks after 23-gauge pars plana vitrectomy. Retina. 2015;35(5):886–891. doi:10.1097/IAE.0000000000000416 [CrossRef]
- Wickham L, Connor M, Aylward GW. Vitrectomy and gas for inferior break retinal detachments: Are the results comparable to vitrectomy, gas, and scleral buckle?Br J Ophthalmol. 2004;88(11):1376–1379. doi:10.1136/bjo.2004.043687 [CrossRef]
- Stavrakas P, Tranos P, Androu A, et al. Anatomical and functional results following 23-gauge primary pars plana vitrectomy for rhegmatogenous retinal detachment: Superior versus inferior breaks. J Ophthalmol. 2017;2017:2565249. doi:. Epub 2017 Jun 4. doi:10.1155/2017/2565249 [CrossRef]
- Sharma A, Grigoropoulous V, Williamson TH. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol. 2004;88(11):1372–1375. doi:10.1136/bjo.2003.041350 [CrossRef]
- Orlin A, Hewing NJ, Nissen M, et al. Pars plana vitrectomy compared with pars plana vitrectomy combined with scleral buckle in the primary management of noncomplex rhegmatogenous retinal detachment. Retina. 2014;34(6):1069–1075. doi:10.1097/IAE.0000000000000050 [CrossRef]
- Ellakwa AF, Galal Zaky A, Hamdy Ghoraba H. Long-term follow-up of vitrectomy, with or without 360 degree encircling buckle, for rhegmatogenous retinal detachment due to inferior retinal breaks. Clin Ophthalmol. 2016;10:1145–1151. doi:10.2147/OPTH.S102082 [CrossRef]
- Goto T, Nakagomi T, Iijima H. A comparison of the anatomic successes of primary vitrectomy for rhegmatogenous retinal detachment with superior and inferior breaks. Acta Ophthalmol. 2012;91(6):552–556. doi:10.1111/j.1755-3768.2012.02455.x [CrossRef]
- Martínez-Castillo V, Verdugo A, Boixadera A, et al. Management of inferior breaks in pseudophakic rhegmatogenous retinal detachment with pars plana vitrectomy and air. Arch Ophthalmol. 2005; 123:1078–1081. doi:10.1001/archopht.123.8.1078 [CrossRef]
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Baseline Clinical Characteristics of Phakic Patients Who Underwent Vitrectomy Alone for Primary RRDs Associated With Inferior Breaks, N (%) or Mean (± SD)
|Age (years), range||61.7 (38 to 82)|
|Male gender||16 (62%)|
|Macula-involving detachments||13 (50%)|
|Number of involved quadrants||2.00 (± 0.70)|
|Number of breaks within the detachment||2.50 (± 2.00)|
|C3F8 gas tamponade||23 (88.5%)|
|SF6 gas tamponade||3 (11.5%)|
|Giant retinal tear||2 (7.7%)|