Article Date: 3/1/2010

Surgery for Primary Rhegmatogenous Retinal Detachment

Surgery for Primary Rhegmatogenous Retinal Detachment

Comparing different methods of repair.

STEPHEN G. SCHWARTZ, MD, MBA • WILLIAM F. MIELER, MD

Despite continued advances in vitreoretinal surgery, primary rhegmatogenous retinal detachment (RD) remains an important cause of visual loss. The two most commonly employed surgical procedures to repair an RD are scleral buckling (SB) and pars plana vitrectomy (PPV),1 although pneumatic retinopexy (PR) is an appropriate option for selected patients.2 Laser demarcation3 and observation4 may be considered in rare cases.

THEORETICAL CONSIDERATIONS

Successful retinal reattachment surgery requires sealing of retinal breaks and relief of vitreoretinal traction.5 SB is the most well-established technique and has the longest available published follow-up data.6 SB is a reasonable choice for most primary retinal detachments (Figure 1). Relative contraindications to SB are primarily related to technical issues with placement of the buckling elements. They are listed in Table 1.

Figure 1. Pre- and postoperative image of a phakic rhegmatogenous RD, which was treated with an encircling scleral buckle. The retina was completely reattached.

Pneumatic retinopexy is the least expensive option and the only major retinal reattachment surgery that can be performed in a clinic setting. The major disadvantage of PR is a relatively low single-operation success rate (SOSR), which has been estimated, from a group of published case series, to be about 74%.7 Of the three major techniques, PR is the most dependent on preoperative patient selection, with better prognoses for patients with phakic RDs, superior breaks, and one or several closely spaced breaks.

Pars plana vitrectomy is increasing in popularity as a first-line treatment for primary RD, especially in pseudophakic cases.8,9 Much of this shift has been driven by technical advances in vitrectomy instrumentation and wide-angle viewing systems (Figure 2).10 PPV has several potential advantages over SB, including removal of vitreous opacities and more controlled drainage of subretinal fluid.11 PPV is unlikely to cause significant induced myopia or motility disturbances, and it is generally less painful than SB.

Figure 2. Early postoperative image from a pseudophakic RD patient, revealing retinal reattachment, with an approximately 50% residual intraocular air bubble.

However, PPV is associated with cataract formation,12 intraocular pressure elevation,13 and new retinal breaks.14 If perfluorocarbon liquids are used, they may be retained in the eye.15 Rare complications of PPV include retinal incarceration into a sclerotomy,16 displacement of a LASIK flap,17 retinal trauma during fluid-air exchange,18 and inferior displacement of the retina.19 PPV and SB are compared in Table 2.

Historically, the risks of PPV were felt to outweigh the benefits in patients with primary RD, but recent case series have reported excellent anatomic and visual results. For example, PPV may be associated with excellent outcomes, even in patients traditionally thought to be poor candidates for PPV, such as cases with inferior breaks20 or with no visible breaks.21 Similarly, excellent outcomes have been reported even with nontraditional surgical techniques, including the use of air22 or aqueous23 tamponade or with the use of very limited positioning requirements.24

EMPIRICAL DATA

A growing number of randomized clinical trials (RCTs) have increased our understanding of the relative strengths and weaknesses of the three major procedures.

The Retinal Detachment Study Group reported 198 patients from seven centers with superiorly located RDs who were randomized to SB or PR and followed for at least six months. SB was associated with a higher SOSR (82% vs 73%), but PR was associated with significantly more favorable visual outcomes.25

Multiple singlecenter RCTs have recently been published comparing SB to PPV (Table 3). In general, these smaller RCTs found no statistically significant differences in either SOSR or visual results between these two surgical approaches.

The Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment (SPR) study is a European multicenter RCT comparing PPV to SB.26 The study group defined a group of “medium-severe” RDs for which there was no apparent advantage between SB and PPV. The study group reported that, based on detailed fundus drawings, 28.2% of RDs qualified as “medium-severe.” These cases were characterized by an average of 2.6 retinal breaks, 5.8 clock hours of detachment, no visible break in 15.1%, macula-on status in 42.9%, bullous subretinal fluid in 15.1%, and vitreous hemorrhage or opacity in 7.7%.27

Forty-five surgeons in 25 centers in five European nations enrolled 416 phakic and 265 pseudophakic patients with “medium-severe” RDs. Patients were randomized to receive SB or PPV, although patients treated with PPV could also receive SB at the discretion of the treating surgeon. The primary endpoint was change in best-corrected visual acuity at one year. The secondary endpoints consisted of various anatomic factors, including SOSR. The results are summarized in Table 4. The study group concluded that SB was preferable in phakic eyes with “medium-severe” RD, and PPV was preferable in pseudophakic eyes, based on the more favorable anatomic results.28 Using statistical modeling, the study group subsequently reported that PPV was associated with an increased risk of recurrent RD in the phakic group and a decreased risk of recurrent RD in the pseudophakic group.29

RECOMMENDATIONS

Despite a growing body of RCT data, there remains no definitive answer to the question, “What is the ideal procedure to treat a primary RD?” The SPR study reported outcomes favoring SB for phakic cases and PPV (or combined SB/PPV) for pseudophakic cases, although the eligibility criteria for this trial excluded over two-thirds of patients with primary rhegmatogenous RD.

Based on this lack of conclusive data, certain recommendations become evident. There does not appear to be a unitary treatment for primary RD, and surgical strategies should be individualized based on a variety of factors. These should include the number, size, and location of the retinal breaks; the lens status; the patient's expected ability to comply with postoperative positioning requirements; the available operating room equipment and support staff; the experience and preferences of the surgeon; and the preferences of the patient and caregivers. Using these guidelines, and the surgeon's best clinical judgment, anatomic reattachment and favorable visual outcomes are achievable for the vast majority of patients with primary rhegmatogenous RD. RP

Stephen G. Schwartz, MD, MBA, is associate professor of clinical ophthalmology at the Bascom Palmer Eye Institute of the University of Miami. William F. Mieler, MD, is professor and vice chair of the Department of Ophthalmology & Visual Sciences at the University of Illinois at Chicago. Neither author reports any financial interest in any products mentioned in this article. Dr. Mieler can be reached via e-mail at wmieler@uic.edu.

REFERENCES

  1. Schwartz SG, Flynn HW. 2008. Pars plana vitrectomy for primary rhegmatogenous retinal detachment. Clin Ophthalmol. 2:57-63.
  2. Tornambe PE. 1997. Pneumatic retinopexy: the evolution of case selection and surgical technique. A twelve-year study of 302 eyes. Trans Am Ophthalmol Soc. 95:551-78.
  3. Vrabec TR, Baumal CR. 2000. Demarcation laser photocoagulation of selected macula-sparing rhegmatogenous retinal detachments. Ophthalmology. 107:1063-7.
  4. Brod RD, Flynn HW Jr., Lightman DA. 1995. Asymptomatic rhegmatogenous retinal detachments. Arch Ophthalmol. 113:1030-2.
  5. Schwartz SG, Mieler W F. 2004. Management of primary rhegmatogenous retinal detachment. Comp Ophthalmol Update. 5:285-94.
  6. Schwartz SG, Kuhl D P, McPherson AR, et al. 2002. Twenty-year follow-up for scleral buckling. Arch Ophthalmol. 120:325-9.
  7. Chan CK, Lin SG, Nuthi ASD, Salib DM. 2008. Pneumatic retinopexy for the repair of retinal detachments: a comprehensive review (1986-2007). Surv Ophthalmol. 53:443-78.
  8. Lois N, Wong D. 2003. Pseudophakic retinal detachment. Surv Ophthalmol. 48:467-87.
  9. SPR Study Group. 2003. View 2. The case for primary vitrectomy. Br J Ophthalmol. 87:784-7.
  10. Weichel ED, Martidis A, Fineman MS, et al. 2006. Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment. Ophthalmology. 113:2033-40.
  11. Brazitikos PD, Androudi S, D'Amico DJ, et al. 2003. Perfluorocarbon liquid utilization in primary vitrectomy repair of retinal detachment with multiple breaks. Retina. 23:615-21.
  12. Ling CA, Weiter JJ, Buzney SM, et al. 2005. Competing theories of cataractogenesis after pars plana vitrectomy and the nutrient theory of cataractogenesis. A function of altered aqueous fluid dynamics. Int Ophthalmol Clin. 45:173-98.
  13. Lee EJ. 2004. Use of nitrous oxide causing severe visual loss 37 days after retinal surgery. Br J Anaesth. 93:464-6.
  14. Al-Harthi E, Abboud EB, Al-Dhibi H, et al. 2005. Incidence of sclerotomy-related retinal breaks. Retina. 25:281-4.
  15. Roth DB, Sears JE, Lewis H. 2004. Removal of retained subfoveal perfluoro-n-octane liquid. Am J Opthalmol. 138:287-9.
  16. Stopa M, Toth CA. 2006. A method to free retina and vitreous from intraoperative incarceration in the sclerotomy. Retina. 26:1070-1.
  17. Tosi GM, Tilanus MA, Eggink C, Mittica V. Flap displacement during vitrectomy 24 months after laser in situ keratomileusis. 2005. Retina. 25:1101-3.
  18. Yang SS, McDonald HR, Everett AI, et al. 2006. Retinal damage caused by air-fluid exchange during pars plana vitrectomy. Retina. 26:334-8.
  19. Shiragami C, Shiraga F, Yamaji H, et al. 2009. Unintentional displacement of the retina after standard vitrectomy for rhegmatogenous retinal detachment. Ophthalmology. Nov 4 [Epub ahead of print].
  20. Sharma A, Grigoropoulos V, Williamson TH. 2004. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol. 88:1372-5.
  21. Martinez-Castillo V, Boixadera A, Garcia-Arumi J. 2009. Pars plana vitrectomy alone with diffuse illumination and vitreous dissection to manage primary retinal detachment with unseen breaks. Arch Ophthalmol. 127:1297-304.
  22. Martinez-Castillo V, Verdugo A, Boixadera A, et al. 2005. Management of inferior breaks in pseudophakic rhegmatogenous retinal detachment with pars plana vitrectomy and air. Arch Ophthalmol. 123:1078-81.
  23. Martinez-Castillo V, Zapata MA, Boixadera A, et al. 2007. Pars plana vitrectomy, laser retinopexy, and aqueous tamponade for pseudophakic rhegmatogenous retinal detachment. Ophthalmology. 114:297-302.
  24. Martinez-Castillo V, Boixadera A, Verdugo A, et al. 2005. Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position. Ophthalmology. 112:1222-6.
  25. Tornambe PE, Hilton G F. Pneumatic retinopexy: a multicenter randomized controlled clinical trial comparing pneumatic retinopexy with scleral buckling. The Retinal Detachment Study Group. Ophthalmology. 96:772-83.
  26. Heimann H, Hellmich M, Bornfeld N, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment (SPR study). 2001. Design issues and implications. SPR study report no. 1. Graefes Arch Clin Exp Ophthalmol. 239:567-74.
  27. Feltgen N, Weiss C, Wolf S, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (SPR Study): recruitment list evaluation. Study report no. 2. 2007. Graefes Arch Clin Exp Ophthalmol. 245:803-9.
  28. Heimann H, Bartz-Schmidt KU, Bornfeld N, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. 2007. Ophthalmology. 114:2142-54.
  29. Heussen N, Hilgers RD, Heimann H, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (SPR Study): Multiple-event analysis of risk factors for reoperations. SPR Study report no. 4. 2009. Acta Ophthalmol. Nov 11 [Epub ahead of print].
  30. Tewari HK, Kedar S, Kumar A, et al. 2003. Comparison of scleral buckling with combined scleral buckling and pars plana vitrectomy in the management of rhegmatogenous retinal detachment with unseen retinal breaks. Clin Exp Ophthalmol. 31:403-7.
  31. Ahmadieh H, Moradian S, Faghihi H, et al. 2005. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation. Report no. 1. Ophthalmology. 112:1421-9.
  32. Sharma YR, Karunanithi S, Azad RV, et al. 2005. Functional and anatomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand. 83:293-7.
  33. Brazitikos PD, Androudi S, Christen WG, Stangos NT. 2005. Primary pars plana vitrectomy versus scleral buckle surgery for the treatment of pseudophakic retinal detachment: A randomized clinical trial. Retina. 25:957-964.


Retinal Physician, Issue: March 2010