Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Outcomes and Complications of In-Office Laser Demarcation of Peripheral Rhegmatogenous Retinal Detachments

David Xu, MD; Hannah J. Levin, BS; Hannah Garrigan, BS; Turner D. Wibbelsman, BS; Anthony Obeid, MD, MPH; Ravi R. Pandit, MD, MPH; Thomas L. Jenkins, MD; Sonia Mehta, MD; Allen C. Ho, MD; Jason Hsu, MD; Carl D. Regillo, MD

Abstract

BACKGROUND AND OBJECTIVE:

To evaluate the outcomes of in-office laser demarcation (LD) for peripheral rhegmatogenous retinal detachments (RRDs).

PATIENTS AND METHODS:

This was a retrospective analysis of peripheral RRDs treated with LD. Patient demographics, visual acuity (VA), and RRD characteristics were recorded. Complications requiring additional procedures were recorded. Multiple logistic regression was used to characterize the association of RRD anatomy to treatment complications.

RESULTS:

A total of 112 eyes of 107 patients were analyzed with mean follow-up of 20 ± 12 months. VA at baseline and last follow-up was equivalent (0.16 logMAR, Snellen equivalent 20/29). Ninety-five (84.8%) eyes were successfully treated without an additional procedure. In multivariate analysis, the presence of VH (odds ratio [OR] = 4.0; 95% confidence interval [CI], 1.1–17; P = .04) and RRDs in the inferior 6 clock hours (OR = 6.2; 95% CI, 1.5–29; P = .01) were associated with complications.

CONCLUSIONS:

LD is successful in treating peripheral RRDs. RRD characteristics less conducive to laser include presence of VH and inferior RRD.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:428–434.]

Abstract

BACKGROUND AND OBJECTIVE:

To evaluate the outcomes of in-office laser demarcation (LD) for peripheral rhegmatogenous retinal detachments (RRDs).

PATIENTS AND METHODS:

This was a retrospective analysis of peripheral RRDs treated with LD. Patient demographics, visual acuity (VA), and RRD characteristics were recorded. Complications requiring additional procedures were recorded. Multiple logistic regression was used to characterize the association of RRD anatomy to treatment complications.

RESULTS:

A total of 112 eyes of 107 patients were analyzed with mean follow-up of 20 ± 12 months. VA at baseline and last follow-up was equivalent (0.16 logMAR, Snellen equivalent 20/29). Ninety-five (84.8%) eyes were successfully treated without an additional procedure. In multivariate analysis, the presence of VH (odds ratio [OR] = 4.0; 95% confidence interval [CI], 1.1–17; P = .04) and RRDs in the inferior 6 clock hours (OR = 6.2; 95% CI, 1.5–29; P = .01) were associated with complications.

CONCLUSIONS:

LD is successful in treating peripheral RRDs. RRD characteristics less conducive to laser include presence of VH and inferior RRD.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:428–434.]

Introduction

In-office laser demarcation (LD) is an accepted treatment modality for small peripheral rhegmatogenous retinal detachments (RRDs) as an alternative to operative repair of RRD by pars plana vitrectomy (PPV), scleral buckling (SB), or pneumatic retinopexy (PR). Treatment involves applying three or more confluent rows of laser photocoagulation surrounding the margins of the detachment to establish a barrier of retina-retinal pigment epithelium (RPE) adhesion preventing further extension of subretinal fluid (SRF).1 The procedure is less invasive than the other means of repair. It also avoids the risks of ocular surgery and anesthesia, has minimal recovery time, is cost-effective, and can be performed on the day of presentation in the office setting.

Prior case series of in-office LD demonstrated excellent results in treating asymptomatic peripheral retinal detachments,2–4 macula-sparing persistent or recurrent detachments following scleral buckling,5 macula-sparing RD in teenagers,6 and even RRDs associated with cytomegalovirus retinitis.7,8 Despite these encouraging results, case selection is an important factor for the success of the procedure. A high rate of failure has been reported for symptomatic RRDs as opposed to those that were asymptomatic.2 Anecdotal teaching has suggested that superior RRD are less suitable for LD, possibly attributed to faster RRD progression that extends beyond the barricade. Apart from this, there is limited guidance to aid in selection of candidates for in-office LD based on the presenting characteristics of the detachment.

The purpose of the present study is to analyze presenting ocular characteristics and anatomic configuration of peripheral RRDs associated with in-office LD and report on the frequency and types of secondary interventions required.

Patients and Methods

Inclusion and Exclusion Criteria

This was a single-center, retrospective, consecutive case series including patients from the offices of Mid Atlantic Retina and the Retina Service of Wills Eye Hospital between January 1, 2015, and December 31, 2018. The study was approved by the institutional review board of the Wills Eye Hospital and adhered to the tenets of the Declaration of Helsinki and the Health Insurance Portability and Accountability Act. A billing record search followed by chart review was used to retrospectively identify cases for inclusion. Cases were included if they had a macula-sparing RRD treated with in-office LD, at least 3 months of follow-up, and an extended ophthalmoscopy fundus diagram recorded on the same office visit used to assess RRD configuration. Patients were excluded if they had prior PPV, SB or PR, previous LD to treat a RRD, retinal scatter photocoagulation, serous or tractional RRD, RRD associated with herpetic or cytalomegavirus retinitis, and hereditary vitreoretinopathies that pre-dispose to retinal detachment (eg, Marfan or Stick-ler syndrome). Based on the fundus diagram, the circumferential width of SRF associated with the RD was graded in clock hours. To restrict analysis to true peripheral RRD rather than retinal tears or holes with surrounding subretinal fluid, only detachments with at least 1 clock hour of SRF were included for analysis.

Laser Demarcation

Patients in the study elected to receive LD after comprehensive discussion of the risks, benefits, and alternatives. Photocoagulation was delivered via laser indirect ophthalmoscopy or a slit-lamp panfunduscopic contact lens. Three to five rows of confluent laser burns were applied posterior to the retinal detachment and anteriorly to the ora serrata. Other peripheral retinal pathology outside of the RRD was treated if needed including additional retinal tears, retinal holes, and lattice degeneration.

Data Extraction and Analysis

Clinical records were reviewed to confirm the diagnosis of RRD. Patient gender, age, RRD laterality, and date of treatment were recorded. Clinical characteristics including best-available visual acuity (VA) based on spectacle-corrected or pinhole Snellen VA, lens status, presence or absence of a complete posterior vitreous detachment (PVD), vitreous hemorrhage (VH), and epiretinal membrane (ERM) were extracted. The fundus ophthalmoscopy diagram was reviewed to grade the clock hour location of RD, circumferential width of RRD, and number and types of retinal breaks (eg, flap retinal tears or retinal holes). VA and presence of ERM was also recorded at 3 months, 6 months, and last follow-up.

The primary outcome was the proportion of eyes that were successfully treated without additional laser or operative procedures. Complications were defined as progression of RRD requiring surgery either with PPV, SB or PR, extension of the region of SRF outside the laser demarcation requiring additional laser treatment, development of significant VH requiring PPV, and formation of a significant ERM requiring PPV within the follow-up duration. The type of complication and time of onset after initial treatment was analyzed. Secondary outcomes included baseline and final VA and the proportion of patients developing any severity of ERM.

Snellen VA was converted to logarithm of the minimum angle of resolution (logMAR) for analysis. The association of each RRD anatomic characteristic to treatment success was analyzed by Fisher's exact test and logistic regression using R version 3.4.1 (R Foundation, Vienna, Austria). The multivariate association of RRD characteristics to treatment success was analyzed by multiple logistic regression. VA was compared by Wilcoxon rank-sum test. A P value less than .05 was considered significant.

Results

Patient Characteristics

During the 4-year study period, a total of 112 eyes of 107 patients were included for final analysis and followed for an average of 20 ± 12 months. Figure 1 illustrates the inclusion and exclusion criteria applied to the study population. The mean patient age was 53 ± 15 years (range: 13 to 79 years), and 97 (86.6%) were phakic. The characteristics of the study eyes are shown in Table 1. Median baseline VA was 0.097 logMAR (Snellen equivalent 20/25) and ranged from −0.097 to 1.0 logMAR (20/16 to 20/200). RRDs were most often (78 of 112 eyes; 69.6%) located in the superior hemiretina between 3- to 9-o'clock with size ranging from 1 to 4 clock hours circumferentially (median: 1.5 clock hours). Forty-four eyes (39.3%) harbored a superotemporal RRD, 16 eyes (14.3%) had a superonasal RRD, 22 eyes (19.6%) had an infero-temporal RRD, and three eyes (2.7%) had an infero-nasal RRD. The causative break was identified in all cases and found to be a retinal flap tear (FT) (66 eyes; 58.9%), retinal hole (RH) (38 eyes; 33.9%), retinoschisis-associated detachment (five eyes; 4.5%), and retinal dialysis (three eyes; 2.7%). The median number of breaks within detached retina was one (range: 1 to 5), and 24 (21.4%) eyes had more than one break within the RRD at presentation. VH was present in 32 eyes (28.6%). Among eyes with VH, all had complete PVD, 30 (93.8%) had FT as the causative break, and two (6.3%) had RH.

Inclusion and exclusion criteria applied to the study population. RD = retinal detachment; SRF = subretinal fluid; PPV = pars plana vitrectomy

Figure 1.

Inclusion and exclusion criteria applied to the study population. RD = retinal detachment; SRF = subretinal fluid; PPV = pars plana vitrectomy

Baseline Demographics and Retinal Detachment Anatomic Characteristics

Table 1:

Baseline Demographics and Retinal Detachment Anatomic Characteristics

Of the 112 eyes, the single-procedure success rate for lasting retinal demarcation was 88.4% (Table 2). Additional treatment was indicated for progression of RRD requiring PPV or SB (nine eyes; 8.0%) or extension of SRF requiring additional laser photocoagulation (six eyes; 5.4%). Two eyes received both additional laser and surgery leading to an overall RRD progression rate of 13 of 112 eyes (11.6%). Additionally, PPV was performed for VH that was non-clearing or that subsequently developed and precluded fundus evaluation in four eyes (3.6%). The initial fundus view was adequate for laser treatment in all eyes. Finally, visually significant ERM developed in five eyes (4.5%) leading to a final complication rate of 17 of 112 eyes (15.2%). Progression of RD occurred within 1 week in seven of 13 eyes (53.8%) and within 3 months in 10 eyes (76.9%) (range: 2 days to 16 months). In those with progression of RD, new PVD symptoms were present in seven of 13 eyes (53.8%), whereas the rest were asymptomatic. Two eyes that progressed initially presented with non-PVD associated detachment. Of these, one eye (50.0%) developed recurrent detachment associated with onset of acute PVD. Of the nine eyes that required operative repair, six (66.7%) underwent combined PPV and SB, two (22.2%) underwent PPV alone, and one (11.1%) received SB alone. Two eyes (22.2%) of nine had macula involving detachments, whereas the remaining seven (77.8%) were macula-sparing. None had evidence of proliferative vitreoretinopathy (PVR) at the time of surgery. One eye that underwent PPV and two eyes that underwent PPV and SB required a second operation to reattach the retina. The final anatomic reattachment rate after all surgeries was 100%. Final VA was 0.097 logMAR (Snellen 20/25) and ranged from 0 to 1.30 logMAR (20/20 to 20/400). VA at last follow-up in eyes that developed RRD requiring operative repair were significantly worse than those that did not (median: 0.30 logMAR [20/40] versus 0.097 logMAR [20/25]; P = .002). All phakic eyes that underwent RRD repair by PPV were pseudophakic at last follow-up. Overall, eyes that required any additional procedure had worse final VA compared to those that did not (median: 0.30 logMAR [20/40] versus 0.097 logMAR [20/25]; P < .001).

Outcomes and Complications of Laser Demarcation

Table 2:

Outcomes and Complications of Laser Demarcation

Mean VA was similar at baseline (0.097 logMAR; Snellen 20/25) and last follow-up (0.097 logMAR; Snellen 20/25; P = .50). We found no statistically significant difference in VA at baseline, 3 months, 6 months, or last follow-up. Chart records and optical coherence tomography (OCT) scans were reviewed for the presence of any severity of ERM. The proportion of patients with ERM was seven eyes (6.3%), 17 eyes (16.7%), 20 eyes (24.1%), and 30 eyes (26.8%) at baseline, 3 months, 6 months, and last follow-up, respectively. ERM was significantly more prevalent by last follow-up (30 of 112 eyes) compared with baseline (seven of 112 eyes; P = .001).

We analyzed the contribution of baseline anatomic characteristics of the RRD to the risk of complications (Table 3). On univariate analysis, significant predictors of complications of LD included presence of PVD (odds ratio [OR] = 4.5; 95% CI, 1.0–29; P = .05), VH (OR = 4.7; 95% CI, 1.5–14; P = .007), and presence of FTs (OR = 3.9; 95% CI, 1.0–17; P = .04) as the causative break. Age (P = .2), gender (P = .2), pseudophakia (P = .2), circumferential width of RD (P = .7), number of retinal breaks within detachment (P = .9), superior versus inferior location of RRD (P = .3), and baseline VA (P = .09) were not significantly associated with complications. Predictors that were included in multivariate model were the significant predictors in univariate analysis and additionally included the anatomic location of RRD. In multivariate analysis, only the presence of VH (OR = 4.0; 95% CI, 1.1–17; P = .04) and RRD in the inferior 6 clock hours (OR = 6.2; 95% CI, 1.5–29; P = .01) were significantly associated with complications.

Univariate (A) and Multivariate (B) Association of Baseline Anatomic Factors to Complications of Laser Demarcation

Table 3:

Univariate (A) and Multivariate (B) Association of Baseline Anatomic Factors to Complications of Laser Demarcation

Discussion

LD is a commonly performed treatment modality for limited peripheral RRD, which can achieve stability of the detachment using a single in-office procedure. We analyzed the presenting ocular features and anatomic configuration of peripheral RD associated with successful treatment. Our results suggest that complications requiring additional treatment were significantly associated with two factors: the presence of vitreous hemorrhage and RD located within the inferior 6 clock hours. After adjusting for other anatomic factors, we found that presence of PVD or flap retinal tears were not more likely to require additional treatment.

The traditional teaching is that superior RRD progresses more quickly and that superior breaks more often lead to detachment.9,10 Thus, superiorly located detachments are believed by some to be less amenable to laser treatment. We sought to specifically analyze this notion using our data and, interestingly, found the opposite relationship to be true. The mechanism by which VH and inferior RRD predisposes to complications may be multifactorial. Both inferiorly settled vitreous blood and the patients' Bells response during treatment may lead to relatively incomplete laser barricade. Additionally, the presence of VH has been associated with larger retinal breaks, which may predispose to greater expansion rate of detachment.9 VH associated with RD has also been associated with worse visual outcomes and higher incidence of PVR.11 Eyes with inferior RD are also more likely to harbor a multiplicity of breaks.9 In our data, we found no significant difference in number of breaks between superior and inferior detachments (P = .15). However, the circumferential width of inferior detachments (1.8 ± 0.7 clock hours) was greater than superior detachments (1.5 ± 0.6 clock hours; P = .02). Finally, inferior RD may be more frequently asymptomatic and may be more chronic, possibly influencing the success rate. Clinicians should be aware of these limitations and exercise caution in treating inferior peripheral RDs using laser, particularly if there is concurrent VH.

Our data suggest that LD for selected, peripheral RRD yields a good overall anatomic success rate (88.4%), which is comparable to primary operative repair using PPV or SB, although the published success rates for the latter procedures are generally in all comers with more extensive RD on average.12–15 Additionally, VA following the procedure is excellent with an equivalent baseline and final VA of 20/29. For patients apprehensive of surgery or who are poor surgical candidates due to systemic medical conditions, LD may be a reasonable alternative for relatively limited RRD. The findings of our study are in agreement with prior studies on laser demarcation of peripheral RRD.2,4,6 Al-Mohtaseb et al.2 evaluated 27 eyes that underwent LD and found that 81% did not require additional treatment. Those that required additional treatment tended to have RRD-related visual symptoms (eg, floaters and photopsias). In our study, a high percentage of patients reported chronic RRD-related symptoms, which were longstanding, thus making accurate determination of acute symptomology unreliable in our retrospective review. Shukla et al.3 studied 19 eyes and found a single-procedure attachment rate of 95%, although the mean age was 26 years and most (15 of 19) cases in their series were caused by retinal holes. Finally, Vrabec et al.4 reported the outcomes of 34 eyes treated with LD yielding stabilization of the RRD in 97%, although the series also included secondary detachment presenting after primary treatment by PPV or SB.

Limitations of the study include its retrospective nature. Individual surgeon judgement was used to select patients for laser therapy and detachments, on average, tend to be relatively small in area compared to detachments repaired by PR, SB, or PPV. This may introduce bias as RRD in various locations may have been selected for differing procedures. Some patients were offered in-office laser if they were apprehensive of surgery or unsuitable for anesthesia due to medical illness, potentially leading to inclusion of patients who would otherwise have received another procedure. Some patients had VH at presentation; however, the amount and severity was not quantitatively graded. This factor may also influence surgeons' decision for surgery or LD. Patients who were lost to follow-up before 3 months were removed from analysis, possibly leading to an inclusion bias if patients sought care elsewhere for treatment complications. It is also possible that new retinal tears outside of the LD could have ultimately led to RD. We comprehensively reviewed fundus ophthalmoscopy diagrams to identify if this occurred; however, this may be missed for small breaks and could potentially lead to overestimation of the failure rate. We performed our analysis based on the location and extent of RRD, rather than location of retinal breaks within the detachment, since patients sometimes had multiple breaks. It is possible that the principle quadrantic location of RD is different than that of the break (ie, predominantly inferior detachment with break above the horizontal); however, most RRDs were relatively limited in size (median: 1.5 clock hours), making this unlikely. Finally, the accuracy of each fundus diagrams may be variable based on the surgeon's examination.

In conclusion, LD is a reasonable approach for treating selected, relatively small peripheral RRDs. RRD characteristics less conducive to laser treatment include presence of VH and inferior RD. Patients should be followed closely after treatment to detect post-laser progression of RD, vitreous hemorrhage, and significant epiretinal membrane formation.

References

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Baseline Demographics and Retinal Detachment Anatomic Characteristics

CharacteristicN (%)

Mean age ± SD, years53 ± 15

Gender, male57 (50.9%)

Lens status
  Phakic98 (87.5%)
  Pseudophakic14 (12.5%)

Presence of posterior vitreous detachment74 (66.1%)

Presence of vitreous hemorrhage32 (28.6%)

Presence of epiretinal membrane7 (6.3%)

Retinal detachment location
  Superior78 (69.6%)
  Inferior34 (30.4%)

Circumferential width
  1 to < 2 clock hours70 (62.5%)
  2 to < 3 clock hours33 (29.5%)
  ≥ 3 clock hours9 (8.0%)

Causative break
  Flap tear66 (58.9%)
  Retinal hole38 (33.9%)
  Retinoschisis5 (4.5%)
  Retinal dialysis3 (2.7%)

Outcomes and Complications of Laser Demarcation

Snellen Visual Acuity, Median (Range)

Baseline20/25 (20/16 – 20/200)
  3 months20/25 (20/20 – 20/200)
  6 months20/25 (20/20 – 20/400)
  Final20/25 (20/20 – 20/400)

ERM
  Baseline7 of 112 (6.3%)
  3 months17 of 102 (16.7%)
  6 months20 of 83 (24.1%)
  Final30 of 112 (26.8%)

Single procedure success rate99 of 112 (88.4%)

Final success rate112 of 112 (100%)

Progression of RD requiring surgery9 of 112 (8.0%)

Progression of RD requiring additional laser6 of 112 (5.4%)

Vitreous hemorrhage requiring surgery4 of 112 (3.6%)

ERM requiring surgery5 of 112 (4.5%)

Univariate (A) and Multivariate (B) Association of Baseline Anatomic Factors to Complications of Laser Demarcation

A
Odds Ratio95% CIP Value
Age.2
Gender.2
Pseudophakia.2
PVD4.51.0–29.05
Vitreous hemorrhage4.71.5–14.007
Inferior RD.3
Width of RD.7
Flap tear3.91.0–17.04
Number of breaks.9
Baseline VA.09
B
Odds Ratio95% CIP Value
PVD.3
Vitreous hemorrhage4.01.1–17.04
Inferior RD6.21.5–29.01
Flap tear.4
Authors

From Retina Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania.

Presented at the Retina Society meeting in London, England, on September 12, 2019.

The authors report no relevant financial disclosures.

Address correspondence to Carl D. Regillo, MD, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut St., Suite 1020, Philadelphia, PA 19107; email: cregillo@midatlanticretina.com.

Received: December 09, 2019
Accepted: July 01, 2020

10.3928/23258160-20200804-02

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