Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Surgical Outcomes of Primary RRD With and Without Concurrent Full-Thickness Macular Hole (PRO Study Report No. 7)

Matthew R. Starr, MD; Anthony Obeid, MD; Edwin H. Ryan, MD; Xinxiao Gao, MD; Doug Matsunaga, MD; Malika L. Madhava, BS; Sean M. Maloney, MD; Adam Z. Adika, MD; Krishi V. Peddada, MD; Kareem Sioufi, MD; Michael Ammar, MD; Luv G. Patel, MD; Claire Ryan, BA; Nora J. Forbes, MS; Antonio Capone, MD; Geoffrey G. Emerson, MD, PhD; Daniel P. Joseph, PhD, MD; Dean Eliott, MD; Carl D. Regillo, MD; Jason Hsu, MD; Yoshihiro Yonekawa, MD; Omesh P. Gupta, MD, MBA; for the Primary Retinal Detachment Outcomes (PRO) Study Group

Abstract

BACKGROUND AND OBJECTIVE:

Non-causal macular holes (MHs) can occur concurrently with rhegmatogenous retinal detachments (RRDs). The visual outcomes and surgical approach for these eyes are variable.

PATIENTS AND METHODS:

This was a multi-institutional, retrospective review of all primary retinal detachment surgeries from January 1, 2015, through December 31, 2015. Pre-, intra-, and postoperative metrics were recorded.

RESULTS:

There were 2,242 eyes that had pars plana vitrectomy for primary RRD, 43 (1.9%) of which had a MH at the time of surgery. The mean postoperative logMAR visual acuity (VA) for the MH cohort was 0.87 ± 0.64 (20/148) and for eyes without a MH was 0.47 ± 0.63 (20/59; P < .0001). The single-surgery re-attachment rate for the MH cohort and no MH cohort was 86.1% and 84.9%, respectively (P = 1.0000).

CONCLUSIONS:

Patients with noncausal MHs and RRD had significantly worse VA than patients without a MH. Preoperative counseling is imperative in patients with both RRD and MH.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:500–505.]

Abstract

BACKGROUND AND OBJECTIVE:

Non-causal macular holes (MHs) can occur concurrently with rhegmatogenous retinal detachments (RRDs). The visual outcomes and surgical approach for these eyes are variable.

PATIENTS AND METHODS:

This was a multi-institutional, retrospective review of all primary retinal detachment surgeries from January 1, 2015, through December 31, 2015. Pre-, intra-, and postoperative metrics were recorded.

RESULTS:

There were 2,242 eyes that had pars plana vitrectomy for primary RRD, 43 (1.9%) of which had a MH at the time of surgery. The mean postoperative logMAR visual acuity (VA) for the MH cohort was 0.87 ± 0.64 (20/148) and for eyes without a MH was 0.47 ± 0.63 (20/59; P < .0001). The single-surgery re-attachment rate for the MH cohort and no MH cohort was 86.1% and 84.9%, respectively (P = 1.0000).

CONCLUSIONS:

Patients with noncausal MHs and RRD had significantly worse VA than patients without a MH. Preoperative counseling is imperative in patients with both RRD and MH.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:500–505.]

Introduction

Management of concomitant, noncausal macular holes (MHs) and rhegmatogenous retinal detachments (RRDs) presents a unique surgical scenario. Previous reports suggest a noncausal MH incidence of approximately 1% to 3% at the time of RRD surgery.1–3 These MHs are much different than the myopic MHs and subsequent posterior retinal detachments (RDs) that develop and propagate anteriorly. Successful management of myopic MHs and macula-involving RDs requires closure of the MH, whereas treating RDs associated with noncausal MHs does not necessarily require hole closure for successful RD repair. It is well known that idiopathic MHs form due to an abnormal vitreoretinal traction at the interface of the vitreous gel and the fovea,4,5 and given the similarity of these tractional forces and PVD formation, it is understandable as to why noncausal MHs are sometimes diagnosed simultaneously at the time of a RRD.

Since Kelly and Wendel first described the successful surgical correction of MH using pars plana vitrectomy (PPV),6 previous studies — mostly case series — have described various surgical techniques for performing concomitant MH and RRD repair.3,7–10 There are, however, limited data regarding comparative cohort studies of eyes with and without MH undergoing PPV for RRD repair. The purpose of this report was to compare the visual and anatomic outcomes between eyes with and without noncausal, concomitant MHs at the time of RRD surgery. This study was a multi-institutional study examining outcomes during a single year regarding concomitant surgical repair of both MHs and RRDs. An additional secondary analysis examining internal limiting membrane (ILM) peeling during RRD surgery in those eyes with MH formation was also performed.

Patients and Methods

This study is in compliance with HIPAA, received approval from all institutional review board sites, and adhered to the tenets of the Declaration of Helsinki. Patients who underwent primary PPV or PPV with scleral buckle (SB) for repair of primary RRD from January 1, 2015, through December 31, 2015, from VitreoRetinal Surgery in Minneapolis, The Retina Center in Minneapolis, The Retina Institute in St. Louis, Associated Retinal Consultants/William Beaumont Hospital in Detroit, Massachusetts Eye & Ear in Boston, and Mid Atlantic Retina/Wills Eye Hospital in Philadelphia were included in the database. Complex retinal detachments including recurrent RDs and tractional RDs, eyes with fewer than 3 months postoperative follow-up, and eyes with RDs that underwent treatment with primary scleral buckling, laser retinopexy barricade, or pneumatic retinopexy without PPV were excluded. Eyes with RDs presumed due to a MH (no peripheral breaks) were excluded, and only MHs presumed to be noncausal (with peripheral breaks or anterior subretinal fluid [SRF]) were included.

Detailed demographic, preoperative, intraoperative, and postoperative follow-up variables were collected from each site using the secure online Research Electronic Data Capture database.11 The primary outcomes considered were single-surgery reattachment rate, postoperative VA, and MH closure rate. Single-surgery reattachment was defined as posterior RD with no tamponade present and no presence of SRF that could spread at 3 months postoperatively. Secondary outcomes included use of intraoperative dyes, gas tamponade, preoperative macular status, combined PPV and SB, and ILM peeling. A secondary analysis comparing the visual and anatomic outcomes of eyes with MH that underwent ILM peeling versus those eyes that did not have ILM peeled was also performed. MHs were identified preoperatively and confirmed with optical coherence tomography (OCT).

For statistical analysis, we used JMP software version 15.0 (SAS Institute, Cary, NC). For within-group comparisons between baseline and final metrics, a paired t-test was used, and for comparisons between groups, the Wilcoxon rank-sum test was performed. Group comparisons of the categorical data were performed using Fisher's exact test. A multivariate regression analysis on final postoperative VA was performed controlling for preoperative VA, macular status at the time of surgery, single-surgery reattachment rate, time to RRD repair, signs of RRD chronicity, ILM peeling, and a P value less than .05 was considered to be statistically significant.

Results

There were 2,242 eyes that met the inclusion criteria of having PPV or combined PPV and SB for a primary RRD during the study period, with 1,330 eyes (59.3%) undergoing primary PPV and 912 eyes (40.7%) undergoing combined PPV with SB. The mean age of the patients was 61.8 ± 11.3 years, with 34.8% being female. The mean follow-up after surgery was 360 ± 185 days. The mean preoperative logMAR VA for all eyes was 1.11 ± 1.09 (Snellen VA 20/258), and the mean postoperative logMAR VA was 0.48 ± 0.63 (Snellen 20/60; P < .0001). The single-surgery re-attachment rate for all eyes was 84.9%.

Of these 2,242 eyes with RRDs, 43 eyes (1.9%) had a MH noted preoperatively. Detailed demographic data are listed in Table 1, but briefly, the mean preoperative logMAR VA for the eyes with a MH was 2.04 ± 0.94 (Snellen 20/2193) and for the eyes without a MH was 1.10 ± 1.08 (20/252; P < .0001). The mean postoperative logMAR VA for the MH cohort was 0.87 ± 0.64 (20/148) and for eyes without a MH was 0.47 ± 0.63 (20/59; P < .0001). Eyes with preoperative MH had a significantly larger logMAR improvement in VA following surgery, 1.27 ± 1.03 versus 0.69 ± 1.07 (P < .01). Regarding final VA, when controlled for pre-operative VA, macular status at the time of surgery, single-surgery reattachment rate, time to RRD repair, signs of RRD chronicity, and ILM peeling, eyes with MHs still had worse final VA (P = .02). When only examining macula-off RRDs, the mean postoperative vision in the cohort of eyes without a MH was 0.58 ± 0.69 (20/76) versus 0.90 ± 0.63 (20/159) in eyes with a MH (P < .0001). This difference did not remain significant, though, when controlling for ILM peeling, preoperative vision, single-surgery reattachment rate, silicone oil use, and preoperative lens status (P = .6590). The single-surgery reattachment rate for the MH cohort and no MH cohort was 86.1% and 84.9%, respectively (P = 1.00). All eyes with a MH that re-detached had closure of the MH with a single surgery but developed re-detachments of the retina that were subsequently repaired. Eyes with MHs were more likely to have adjunctive dyes used intraoperatively, peeling of the ILM during surgery, macula-off RDs, drainage of SRF through a drainage retinotomy, use of a long-acting gas tamponade, and use of silicone oil (Table 2). There was no difference in the use of perfluorocarbon, concomitant scleral buckling at the time of surgery, posterior vitreous detachment rate, single-surgery reattachment rate, time from subjective symptom onset, signs of RRD chronicity, or number of peripheral retinal breaks in detached retina (Table 2). Not all cases of MH RRDs were macula-off, with 11 eyes having macula-on RRD with a concomitant MH at the time of surgery. There was one eye that did not have retinal break noted pre- or intraoperatively, but it was not felt to be a primary RD due to the MH given the extensive anterior SRF. This eye had a primary vitrectomy, 360° laser retinopexy with no peeling of the ILM with successful MH closure and single-surgery reattachment success.

Demographic Metrics and Visual and Anatomic Data Comparing Eyes With a Simultaneous Noncausal MH and Retinal Detachment Versus Eyes Without a MH

Table 1:

Demographic Metrics and Visual and Anatomic Data Comparing Eyes With a Simultaneous Noncausal MH and Retinal Detachment Versus Eyes Without a MH

Intraoperative Metrics Comparing Eyes With a Simultaneous Noncausal MH and RD Versus Eyes Without a MH Undergoing Surgical Repair

Table 2:

Intraoperative Metrics Comparing Eyes With a Simultaneous Noncausal MH and RD Versus Eyes Without a MH Undergoing Surgical Repair

When analyzing only those eyes that had MHs by peeling or no peeling of the ILM, there were 22 eyes that had the ILM peeled, whereas 21 eyes did not have the ILM peeled. Eyes that underwent ILM peeling at the time of surgery had significantly worse preoperative VA (logMAR 2.39 [Snellen 20/4909] vs. logMAR 1.67 [Snellen 20/935]; P = .03), but there was no difference postoperatively (logMAR 0.88 [Snellen 20/152] vs. logMAR 0.94 [Snellen 20/174]; P = .459). The eyes that did have the ILM peeled, though, did have a significantly larger overall change in VA with a mean change in logMAR VA of 1.62 versus a mean change of 0.79 in those eyes without ILM peeling (P < .01). There were no differences in single-surgery reattachment rate or MH closure rate. The only eye that did not close with a single surgery belonged to the no ILM peeling cohort. This eye was macula-on preoperatively, underwent primary vitrectomy with a drainage retinotomy with no perfluorocarbon use, and the tamponading agent was octofluoropropane (C3F8). Lastly, the ILM peeling cohort had significantly more use of intraoperative dyes, but individually there was no difference in indocyanine green (ICG) or triamcinolone use (Table 3).

Demographic/Intraoperative Metrics and Visual/Anatomic Outcomes in Eyes With Concomitant MH and RRD Repair Comparing Eyes With and Without Peeling of the ILM at Time of Surgical Repair

Table 3:

Demographic/Intraoperative Metrics and Visual/Anatomic Outcomes in Eyes With Concomitant MH and RRD Repair Comparing Eyes With and Without Peeling of the ILM at Time of Surgical Repair

Discussion

In our study, we report good anatomic outcomes when managing concomitant MHs and RRD with a single surgery. In line with previous studies, we report an incidence of noncausal MHs at the time of RRD surgery of 1.9%. Our data suggest the presence of a preoperative MH adversely affects the visual outcome. These eyes had significantly worse postoperative VA of approximately 20/160 versus the approximately 20/60 vision in eyes without MHs at the time of RRD surgery. Even macula-off RRDs without a MH had significantly better postoperative vision at approximately 20/76 as opposed to macula-off RRDs with a MH at approximately 20/160, although this did not remain significant on multivariate analysis. Preoperative MHs appear to significantly limit VA outcomes.

Prior to the report of Kelly and Wendel and their success of achieving MH closure with the vitrectomy,6 previous techniques of RRD repair had not focused on MH closure.7 Additionally, as the use of PPV has gained increasing popularity as the initial surgical management of RRDs for many surgeons,12 PPV has become the best initial option for repair of concomitant MH and RRD. Initial reports of combined surgical repair of MH with RRD without ILM peeling found a very poor MH closure rate of approximately 31%.13 However, in a more recent study of 49 eyes with non-causal MH and RRD by Ryan et al., 43 eyes underwent ILM peeling, whereas the remaining six eyes did not undergo ILM peeling. The single-surgery MH closure rate in the ILM peeling cohort was 91%, whereas the single-surgery hole closure rate in the non-ILM peeling cohort was 33%.3 This report did not utilize ICG dye and the study was performed before Brilliant Blue (D.O.R.C. Dutch Ophthalmic Research Center, The Netherlands) became widely available. The study concluded it is reasonable to consider ILM peeling without the aid of dyes at the time of surgery and still achieve successful MH closure rates. This study by Ryan et al., however, did implement a prolonged period of face-down positioning for approximately 7 days. Despite the prolonged positioning, the report concluded that ILM peeling was the crucial step in achieving successful MH closure and is able to be performed simultaneously during RRD repair and lead to successful retinal re-attachment.

In our study, however, only about one-half of the eyes had ILM peeling, and we found no difference in final VA, single-surgery reattachment rate, or MH closure rate, although, no definitive conclusions can be made given the small sample size of 43 eyes in a retrospective series. Although the difference in single-surgery reattachment rate was not significantly difference between the ILM peeling cohort and non-peeling MH cohorts, eyes that had the ILM peeled at the time of RRD repair tended to have a higher single-surgery reattachment rate at 90.9% versus 77.8% in the non-ILM peeling cohort. Perhaps peeling of the ILM may provide added benefit to the overall surgical success rate for both hole closure and retinal re-attachment. Additionally, the eyes with ILM peeling did have a significantly larger change in VA, although this is difficult to interpret in the setting of significantly worse preoperative VA. In addition, the only eye that did not close with a single surgery belonged to the non-ILM peeling cohort. Similarly, a study of 31 eyes by Shukla et al., of which 17 eyes underwent ILM peeling at the time of RRD repair, found no difference in MH closure rate or retinal re-attachment rate, but did note a significantly worse final VA in the ILM peeling cohort (20/200 versus 20/80 in the non-ILM peeling cohort [P < .0001]).9 This is in contrast to our study, as we did not find a difference in final VA between the two cohorts. Similarly, we did not see a significant difference in MH closure rate or retinal re-attachment rate, although the only hole that did not close in our study was in the non-ILM peeling cohort. Perhaps prone positioning with gas tamponade alone in the setting of RRD surgery is sufficient to close the MH. This leads to less manipulation of the delicate macular retina during surgery and avoids any controversy surrounding the use of ILM staining dyes with retinal toxicity14–16 and perhaps still achieve similar postoperative outcomes. This may also explain the use of more silicone oil in the MH cohort. Perhaps some surgeons felt a longer macular tamponade would increase MH closure rates.

This study is limited inherently by its design as a retrospective analysis. Additionally, as with any surgical study with multiple centers and different surgeons, a number of intraoperative and postoperative factors cannot be accounted for that could bias the results, such as type of gas tamponade, area of ILM peel, and postoperative positioning. The use of intraoperative dyes to stain the ILM was also varied amongst the surgeons as the use of ICG, Brilliant Blue (only used in three eyes), and triamcinolone was varied; additionally, this metric was not available for all patients, again limiting some of the results obtained. The biggest limitation is the lack of surgical controls in the secondary analysis regarding ILM peeling. Additionally, the mean follow-up in the study was approximately 1 year, and it is possible that some of the patients with MHs that initially closed could have re-opened leading to a falsely elevated single-surgery hole closure rate. The postoperative OCT results were only recorded as hole closed or open, and no other information regarding type of closure can be determined from that data metric. Certainly, it would be interesting to assess macula-on versus macula-off RRD with MH, but due to the low number of maculaon RRDs with MH, we felt the numbers were too low to compare these metrics. Additionally, with numerous surgeons with varied techniques, limits the ability to analyze these types of metrics and potentially limits the generalizability of this data given the small cohort. Intraoperative factors during surgery cannot be accounted for and controlled during a multicenter study and could bias the results, but still the results indicate that successful MH closure rate can be achieved without ILM peeling, and further follow-up studies are needed in this more recent era of vitreo-retinal surgery.

In conclusion, patients with concomitant, non-causal MH identified preoperatively or intraoperatively during primary RRD repair have a relatively high rate of successful visual and anatomic outcomes with or without ILM peeling. Surgeons should counsel patients that RRD with preoperative MH formation, despite successful anatomic closure postoperatively, does appear to limit postoperative visual outcomes compared to eyes that did not have a MH at the time of RRD surgery.

References

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Demographic Metrics and Visual and Anatomic Data Comparing Eyes With a Simultaneous Noncausal MH and Retinal Detachment Versus Eyes Without a MH

Eyes With Macular Hole (n = 43)Eyes Without a Macular Hole (n = 2,209)P Value
Mean Age (Years)61.3 ± 14.361.8 ± 11.2.7688
Sex (Female)21 (48.8%)764 (36%).0740
Pre-logMAR (Snellen)2.04 ± 0.94 (20/2193)1.10 ± 1.08 (20/252)< .0001*
Post-logMAR (Snellen)0.87 ± 0.64 (20/148)0.47 ± 0.63 (20/59)< .0001*
P Value< .0001*< .0001*
Mean Change in logMAR VA1.27 ± 1.030.69 ± 1.07.0017*
Single Surgery RRD Repair86.10%84.90%1.000
Mean Number of Retinal Breaks1.5 ± 1.21.9 ± 2.7.1359
Posterior Vitreous Detachment Status60.5%60.9%.6265
Mean Follow-Up (Days)374 ± 169360 ± 185.4710

Intraoperative Metrics Comparing Eyes With a Simultaneous Noncausal MH and RD Versus Eyes Without a MH Undergoing Surgical Repair

Eyes With MH (n = 43)Eyes Without MH (n = 2,209)P Value
Eyes With Intraoperative Dye17 (39.5%)266 (12.0%)< .0001*
Eyes With Intraoperative Triamcinolone12 (27.9%)251 (11.3%).0038*
Eyes With Intraoperative ICG7 (16.3%)15 (6.8%)< .0001*
Eyes With Intraoperative PFO8 (18.6%)322 (14.6%).5108
Eyes With ILM Peeling22 (51.2%)86 (3.9%)< .0001*
Eyes With Concomitant SB Surgery23 (53.5%)1,332 (60.3%).4338
Eyes With Preoperative Macula-Off Detachments32 (74.4%)1,108 (50.2%).0031*
Eyes With Gas Tamponade34 (79.1%)2,065 (93.5%)< .0001*
Eyes With C3F8 Tamponade23 (53.5%)932 (42.2%).0138*
Eyes Drained Through Retinotomy29 (67.4%)1,031 (46.7%).0242*
Mean Time to RRD Repair After Symptom Onset (Days)4.8 ± 1.64.4 ± 1.8.1841
Eyes With Signs of RRD chronicity5 (11.6%)119 (5.4%).0792

Demographic/Intraoperative Metrics and Visual/Anatomic Outcomes in Eyes With Concomitant MH and RRD Repair Comparing Eyes With and Without Peeling of the ILM at Time of Surgical Repair

Eyes With ILM Peeling (n = 22)Eyes Without ILM Peeling (n = 21)P Value
Mean Age (Years)61.9 ± 15.361.1 ± 14.2.8171
Sex (Female)9 (40.9%)11 (52.4%).3406
Pre-logMAR (Snellen)2.39 ± 0.67 (20/4909)1.67 ± 1.05 (20/935).0271*
Post-logMAR (Snellen)0.88 ± 0.71 (20/152)0.94 ± 0.56 (20/174).4539
P Value< .0001*< .0001*
Mean Change in logMAR VA1.62 ± 0.910.79 ± 0.95.0089*
Single Surgery RRD Repair90.90%77.80%.3810
Single Surgery MH Repair22 (100%)20 (95.2%).4286
Eyes With Intraoperative Dye13 (59.1%)3 (14.2%).0097*
Eyes With Intraoperative Triamcinolone9 (40.9%)2 (9.5%).9312
Eyes With Intraoperative ICG6 (27.3%)1 (4.8%).6866
Eyes With C3F8 Gas Tamponade11 (50.0%)9 (42.9%).9806
Authors

From Mid Atlantic Retina, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania (MRS, AO, XG, DM, MLM, SMM, KS, MA, LGP, CDR, JH, YY, OPG); VitreoRetinal Surgery, Minneapolis, Minnesota (EHR, CR, NJF); Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania (AZA); the Department of Ophthalmology, Drexel University College of Medicine, Philadelphia, Pennsylvania (KVP); Associated Retinal Consultants, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan (AC); The Retina Center, Minneapolis, Minnesota (GGE); The Retina Institute, St. Louis, Missouri (DPJ); and Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts (DE).

Supported by Phillips Eye Institute Foundation, VitreoRetinal Surgery Foundation.

Dr. Eliott is a consultant for Alcon and Dutch Ophthalmics, a stockholder in Aldeyra Therapeutics, and on the scientific advisory board for Pykus Therapeutics. Drs. Gupta and Yonekawa are consultants for Alcon. Dr. Regillo is a consultant for Alcon and a stockholder in Aldeyra Therapeutics. Dr. Capone receives grant support from Alcon. Dr. Ryan receives royalties from Alcon. Dr. Emerson is a stockholder in Valiant and Glaukos. The remaining authors report no relevant financial disclosures.

Address correspondence to Omesh P. Gupta, MD, MBA, Mid Atlantic Retina, Retina Service of Wills Eye Hospital, 840 Walnut St., Suite 1020, Philadelphia, PA, 19107; email: ogupta@midatlanticretina.com.

Received: March 13, 2020
Accepted: July 09, 2020

10.3928/23258160-20200831-04

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