"Well, Doc, What Would You Do if it Were Your Eye?"
The case of the failing, pseudophakic macula-on retinal detachment.
PAUL E. TORNAMBE, MD
HB, a 64-year-old pseudophakic Caucasian male, presented for a second opinion on a failed retinal detachment operation on his right eye. Five days earlier, he had been treated with focal laser to wall off a super ior temporal detachment. There was neither a history of trauma, high myopia nor a family history of retinal detachment. He was otherwise healthy with no skeletal problems.
Physical examination revealed a visual acuity (VA) of 20/25 OU. The right eye had a posterior chamber intraocular lens and an open capsule. A superior temporal retinal detachment was present secondary to 2 horseshoe tears, at 9:30 and 11:30, located at the equator at each end of a circumferential superior temporal patch of lattice degeneration. Subretinal fluid extended several disc diameters posterior to several rows of laser edema. The vitreous showed mild pigment, there was no vitreous blood, and there were no other holes, tears, lattice, or star folds.
The fellow eye showed no lattice or tears and had no prior retinal treatment. A 25-g pars plana vitrectomy was scheduled for the next day by the treating doctor, who was in the last week of a 2-year fellowship at an outstanding university. The patient stated that the staff physician did not examine him and may not have been involved in this decision-making process. The patient also told me I was selected for a second opinion because I treated his wife for retinal tears in the past; however, I was not on his insurance plan.
|Paul E. Tornambe, MD, is a retinal specialist with San Diego Retinal Research Foundation in Poway, CA. He reports no financial interests in any products mentioned in this article. Dr. Tornambe can be reached via e-mail at TornambePE@aol.com.|
I told the patient the prior laser treatment was entirely appropriate, but more surgery was indicated. His treatment options included: more posterior laser; pneumatic retinopexy; a scleral buckle; or vitrectomy, with or without a buckle. I said that prompt treatment was necessary and that surgery should be performed before the macula became involved. We then discussed his options in more detail.
I informed him that more laser treatment was the least invasive but unfortunately carried the lowest success rate due to persistent vitreous traction. Also, additional posterior laser applications might permanently compromise peripheral vision. Pneumatic retinopexy was discussed. In his case, I felt PR carried approximately a 77% single-operation success rate (pseudophakic eye, multiple breaks, 1 quadrant detached). I also told him that if the pneumatic operation failed, it would neither disadvantage his eye to ultimate attachment nor compromise the final visual outcome. If successful, there was a 91%+ chance he would maintain the present preoperative 20/25 VA and a 94% chance he would have 20/40 or better VA.2 I informed him that PR is performed in the office and surgery would take about 30 minutes. This procedure would require positioning on the left side, 16 hours per day, for 3 to 5 days.
Scleral buckling surgery (segmental or encircling) was also discussed. He was told scleral buckling carried a 90%+ single-operation success rate but would likely have refractive issues (myopia, astigmatism, diplopia) and is associated with a 5% to 10% extrusion rate. I told him that there was an 83% chance he would maintain the present preoperative 20/25 vision if the first scleral buckling procedure was successful.1 He was also informed that, with scleral buckling, there was a 92% chance he would have 20/40 or better vision.1 The surgery would take about an hour and would be performed in the operating room.
Vitrectomy (sans buckle) was discussed. I told him that recent, nonrandomized vitrectomy studies2,3 reported a 74% to 92% single-operation success rate in pseudophakic eyes but, unlike scleral buckling, would not have refractive side effects. I informed him that vitrectomy surgery would take about an hour to perform under local anesthesia in an operating room. I told him that these studies reported final VA of 20/40 or better in 70% to 75% of eyes with macula on retinal detachments.2,3
THE KEY QUESTION
After a lengthy discussion, with his wife present, he responded, "Well, what would you do if it were your eye?" My response was, "I would try pneumatic retinopexy first." I told him I felt he was a good candidate for pneumatic retinopexy for several reasons: I could examine the entire peripheral retina, felt confident there were no other breaks, and believed he was reliable and could position himself properly. Most importantly, I told him I felt PR had the best chance of maintaining his present 20/25 vision. I stressed that if pneumatic retinopexy was performed and the holes did not close within 24 to 48 hours, a prompt vitrectomy would be performed, likely with a scleral buckle. I offered to call the staff university retina specialist regarding my examination and advice.
The family asked what it would cost to have the procedure performed "out of plan" and then asked me to perform the procedure. PR was performed using light focal cryopexy to the lattice and tears and a 0.25 mL paracentesis with a #27 plungerless TB syringe, followed by injection of 0.5 mL of SF6 gas. Peripheral 360 laser was not performed because the view of the peripheral retina was excellent and I felt all pathology was adequately addressed. He was positioned for 3 days and then returned to full activity 2 weeks later. The retina attached. His VA is 20/25.
There are several take-home lessons from this case. Many retinal surgeons are reluctant to advise PR in a pseudo phakic eye or an eye with lattice degeneration. The PR clinical trial did not enroll patients with more than 3 clock hours of lattice degeneration; however, eyes with less than 3 clock hours of lattice did not exhibit decreased pneumatic success. Although PR success is lower in pseudophakic eyes, so are other retinal reattachment operations. Pseudophakia is not a contraindication to PR as long as the peripheral retina can be completely examined. The PR clinical trial reported a new/missed break rate of 23%, a 3% proliferative vitreoretinopathy (PVR) rate, and a 99% final attachment rate. In my opinion, most failed pneumatic cases are due to missed breaks rather than new breaks.4 Although eyes with multiple breaks probably have a lower success rate with PR (multiple breaks suggest abnormal vitreoretinal relationships), detachments with multiple breaks more than 1 clock hour apart are not a contraindication.
There are 2 compelling reasons to try PR first. First, PR gives the best visual results. The PR clinical trial1 showed that, in the group of eyes with the macula attached, 20/20 or better VA was attained more frequently in eyes treated with PR than scleral buckling (PR= 57% vs SB=29%). We operate for vision, not single-operation success. Second, if the pneumatic operation is performed properly and fails, and failures are operated on promptly, the pneumatic operation will neither compromise the eye's potential for ultimate reattachment nor jeopardize the eye's visual potential.1
Vitrectomy carries its own share of problems. Vitrectomy does not prevent new break formation, and it is not without significant morbidity. Lai3 reported new breaks in 11% of failed detachments treated with 25-g vitrectomy and a 17% PVR rate. Mendrinos2 reported a 25% incidence of missed breaks before vitrectomy surgery and created retinal breaks in 16% during the vitrectomy operation. In eyes with preoperative attachment of the macula, neither study reported VA results as good as PR (20/40 or better vision: PR=94%; PPV=70%-75%).
PR was selected in this case for several reasons. The patient was compliant, understood the procedure, had excellent family support, and had no physical or mental issues that might have compromised the outcome. When performing PR, the patient is your "cosurgeon." The eye could be thoroughly examined; although pseudophakic, the media were clear, permitting a complete detailed examination of the retinal periphery. The detachment was secondary to superior breaks and was localized to a single quadrant. Although the breaks were more than 1 clock hour apart, the breaks were close enough to be closed by a routine-sized bubble without the need for sequential posturing. Lattice degeneration did not affect the outcome. However, eyes with lattice degeneration may develop new breaks in normal appearing retina. Lattice may be a "signpost" of abnormal vitreoretinal attachments. I would not have advised PR if lattice extended beyond 3 clock hours or if the fellow eye sustained a giant tear. There are many ways to reattach the retina. Final VA, not single-operation success, should be the primary factor when considering which operation to select. RP
- Tornambe PE, Hilton GF; Retinal Detachment Study Group. Pneumatic retinopexy. A two-year follow-up study of the multicenter clinical trial comparing pneumatic retinopexy with scleral buckling. Ophthalmology. 1991;98:1115-1123.
- Mendrinos E, Dang-Burgener N, Stangos A, et al. Primary vitrectomy without scleral buckling for pseudophakic retinal detachment. Am J Ophthalmol. 2008;145:1063-1070.
- Lai M, Ruby A, Sarrafizadeh R, et al. Repair of primary rhegmatogenous retinal detachment using #25 transconjunctival sutureless vitrectomy. Retina. 2008; 28:729-734.
- Tornambe PE. Pneumatic retinopexy: the evolution of case selection and surgical technique. A twelve-year study of 302 eyes. Trans Am Ophthalmol Soc. 1997;95:551-578.