|Year : 2013 | Volume
| Issue : 2 | Page : 122-126
Evaluation of rhegmatogenous retinal detachment treatment by pars plana vitrectomy alone versus pars plana vitrectomy with a scleral buckle
Hamouda H Ghoraba1, Saber H El Sayed2, Khaled G Said2, Amin F Ellakwa2, Adel G Zaky2
1 Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||08-Apr-2013|
|Date of Acceptance||06-Jun-2013|
|Date of Web Publication||31-Jan-2014|
Adel G Zaky
Department of Ophthalmology, Faculty of Medicine, Menoufia University Hospital, Shebin El Kom, 32511, Menoufia
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare and report the anatomic and functional results of primary vitrectomy with scleral buckling versus primary vitrectomy without scleral buckling for the treatment of rhegmatogenous retinal detachment (RRD).
RRD is one of the commonly encountered retinal problems where timely treatment could prevent irreversible vision loss. A variety of options, including scleral buckling, pars plana vitrectomy (PPV) with scleral buckling, pneumatic retinopexy, and a temporary balloon buckle, have been described as methods for repair of RRD.
Patients and methods
A prospective, interventional, comparative case study was carried out. This study included 170 consecutive cases of vitrectomy for primary RRD at two vitreoretinal centers. They were divided into two groups: group I included 95 patients who underwent PPV alone and group II included 75 patients who underwent PPV with a scleral buckle. The main outcome measures were single-surgery anatomic success (SSAS) and final visual acuity (VA).
SSAS was obtained in 160 eyes [89 (93.7%) in group I and 71 (94.7%) in group II]. From overall 111 phakic retinal detachments, SSAS was achieved in 104 eyes [52 in group I (92.9%) and 52 in group II (95.5%)], whereas from overall 59 aphakic or pseudophakic retinal detachments, SSAS was achieved in 56 eyes [37 in group I (94.8%) and 19 in group II (90%)]. VA improvement was greater in the PPV group (P = 0.021).
Both surgical procedures had similar reattachment rates. Intraoperative and postoperative complications were similar considering both the procedures. VA improved significantly in group I (vitrectomy without scleral buckling).
Keywords: Pars plana vitrectomy, rhegmatogenous retinal detachment, scleral buckle
|How to cite this article:|
Ghoraba HH, El Sayed SH, Said KG, Ellakwa AF, Zaky AG. Evaluation of rhegmatogenous retinal detachment treatment by pars plana vitrectomy alone versus pars plana vitrectomy with a scleral buckle. Menoufia Med J 2013;26:122-6
|How to cite this URL:|
Ghoraba HH, El Sayed SH, Said KG, Ellakwa AF, Zaky AG. Evaluation of rhegmatogenous retinal detachment treatment by pars plana vitrectomy alone versus pars plana vitrectomy with a scleral buckle. Menoufia Med J [serial online] 2013 [cited 2020 May 31];26:122-6. Available from: http://www.mmj.eg.net/text.asp?2013/26/2/122/126142
| Introduction|| |
There exists considerable controversy on the best surgical technique to use for repair of phakic and pseudophakic rhegmatogenous retinal detachments (RRDs). Pars plana vitrectomy (PPV) and scleral buckle (SB) surgery remain the most popular techniques used in the primary repair of RRD. Combining these two techniques (PPV/SB) has also become a popular and reliable method for repair of certain types of RRD. Historically, SB has been the method preferred over PPV in the repair of phakic RRD in order to avoid the high incidence of post-PPV cataract formation. However, a significant number of vitreoretinal surgeons seem to be moving away from straight scleral buckling and toward PPV. The avoidance of potential complications of SB, including postoperative myopic shift, epiretinal membrane formation, diplopia, choroidal detachment, eyelid malpositions, and buckle extrusion, is likely to be the main reason for this shift ,,,, . In addition, cataract formation after vitrectomy can be managed with a very high success rate and short operating time using modern phacoemulsification technology. Finally, PPV has been shown in a recent clinical trial to shorten the operating time  .
The preferred method for primary repair of pseudophakic RRD also remains controversial. Several studies have reported better anatomic ,, and functional ,, success rates with PPV than with SB. This may be the result of recent advances in PPV techniques, such as wide-field viewing systems that allow better localization of anterior breaks, commonly encountered in pseudophakic RRD. Of course, PPV also allows meticulous removal of vitreous traction on retinal tears and it allows removal of scattered retinal pigment epithelial cells that may lead to macular pucker and/or proliferative vitreoretinopathy (PVR). Other recent studies have shown at least similar anatomic results for the two procedures ,,,, .
A related controversy is whether to add an encircling buckle after vitrectomy is chosen as the primary procedure for RRD  .
With the recent shift from SB to PPV, it seems logical to pursue studies comparing PPV with PPV/SB for RRD repair. We conducted a prospective, comparative case series evaluating PPV versus PPV/SB for the primary repair of noncomplicated phakic and pseudophakic RRD.
| Patients and methods|| |
A total of 170 patients with primary RRD were admitted for PPV surgery: 95 patients (55.9%) without SB (group I) and 75 patients (44.1%) with SB (group II). Patients with phakic, aphakic, and pseudophakic RRD were included in this study, whereas patients with any of the following characteristics were excluded: age younger than 16 years, recurrent retinal detachment (RD), traumatic retinal detachment, PVR of grade C or worse, visual acuity (VA) of perception of light or less, combined tractional and rhegmatogenous detachment, vitreous hemorrhage, documented follow-up of fewer than 6 months, pre-existing macular disease, or giant tear. Of 170 patients, 170 eyes were identified as study participants. A complete ophthalmological examination was performed including measurement of VA aided and unaided, refraction using an automated refractometer, anterior segment examination using slit-lamp biomicroscopy to detect any pathological disorders, rubeosis iridis, intraocular tension measurement, and posterior segment examination using an indirect ophthalmoscope and slit-lamp biomicroscopy with the three mirror contact lens. All patients gave their formal consent. The protocol was approved by the Ethical Committee of the Faculty of Medicine, Menoufia University.
The patients were fully informed about the technique and the postoperative position. A standard three-port PPV technique using the Accurus surgical system (Alcon Laboratories, Fort Worth, Texas, USA) or Megatron S3 (Hanz Geuder, Heidelberg, Germany) and a noncontact wide-angle viewing system BIOM (Binocular Indirect Ophthalmoscope; Oculus, Wetzlar, Germany) was used in all patients. If a posterior vitreous detachment was not already present, it was created using aspiration by a vitreous cutter or a soft-tip extrusion cannula (flute needle). An attempt was made in every case to shave the vitreous base by 360° using high-speed vitreous cut rates (2500 cuts/min) and low vacuum settings. Subretinal fluid was drained either anteriorly with the assistance of perfluorocarbon or posteriorly by the creation of a posterior retinotomy and air-fluid exchange. Endolaser photocoagulation was performed around all identifiable retinal tears and/or 360° to the vitreous base. A silicon-air exchange using silicon oil (5000 centistokes) was performed in every patient. Appropriate postoperative positioning was requested of each patient for a minimum of 14 days after surgery. In the PPV/SB group, a 360° encircling band (240) was used in an attempt to provide further support to the vitreous base and the retinal breaks. The primary outcome evaluated was single-surgery anatomic success (SSAS) rate. This was defined as a stable retinal reattachment throughout the follow-up period after just one surgery. Secondary outcome measures included the final anatomic success rate, VA improvement, and incidence of postoperative PVR. Landolt's broken ring chart VA test was converted into decimal from VA notations table for statistical analysis. The final anatomic success rate was defined as retinal reattachment at the final follow-up visit, irrespective of the number of surgeries required.
Results were collected, tabulated, and analyzed statistically using an IBM personal computer and statistical package SPSS version 10 (International Business Machines Corporation, Armonk, New York, USA). The paired, two-tailed Student's t-test was used to statistically analyze changes in the VA test. The two-tailed Fisher's exact test was used to compare baseline characteristics and to calculate differences in anatomic outcomes in all groups. A P value of less than 0.05 was considered to be significant.
| Results|| |
In all, 170 eyes were included in the study series. The PPV group included 95 eyes and the PPV plus SB group included 75 eyes. The follow-up period ranged from 6 to 12 months. Preoperative characteristics are summarized in [Table 1]. No tear was found in two (2.1%) and four eyes (5.3%) in the PPV and PPV plus SB groups, respectively. One tear each was found in 48 (50.5%) and 35 patients (46.7%), two or three tears were found in 25 (26.3%) and 28 patients (37.3%), and four tears each were found in 20 (21.1%) and eight patients (10.7%) in the PPV and PPV plus SB groups, respectively. These differences were not statistically significant. The intraoperative data are summarized in [Table 2]. General anesthesia was used more frequently in the PPV plus SB group. Concurrent cataract extraction was performed in a small number of patients (four in group I and five in group II). Of the 56 phakic eyes that underwent PPV alone, 52 (92.9%) achieved SSAS. Of the 55 phakic eyes that underwent combined PPV/SB, 52 (94.6%) experienced successful single-surgery reattachment (P = 0.7). Among aphakic/pseudophakic eyes, 37 of 39 (94.8%) in the PPV group and 19 of 20 (95%) in the PPV/SB group remained reattached after a single surgery (P = 0.93). The final reattachment rates were 100% in group I and 98.2% in group II for phakic patients, whereas it was 97.4% in group I and 100% in group II for aphakic/pseudophakic patients [Table 3].
|Table 3: Comparison between group I and group II in single operation success rate in phakic, aphakic, and pseudophakic patients|
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The mean best-corrected visual acuity (BCVA) in group I was 0.075 and 0.17 decimal preoperatively and final postoperative VA, respectively, whereas in group II it was 0.031 and 0.1 decimal preoperatively and final postoperative BCVA, respectively. There was a statistically significant difference between both groups with respect to best postoperative VA (P < 0.05); also, there was a highly statistically significant difference between preoperative and postoperative VA in each group [Table 4]. The overall incidence of postoperative PVR was 3.2% in the PPV group and 2.7% in the PPV/SB group (P = 0.788). Breaks unrelated to PVR, that is, new breaks, missed breaks, or reopening of known breaks, accounted for two of six redetachments in group I and two of four redetachments in group II. Postoperative PVR with or without associated breaks accounted for the largest proportion of redetachment [Table 5].
|Table 4 Comparison between group I and group II in preoperative and final postoperative best-corrected visual acuity|
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| Discussion|| |
The present study indicates that the addition of an SB did not improve the reattachment rates and the final VA in eyes undergoing PPV for noncomplex RRD. However, as soon as vitrectomy is chosen, the benefit of performing a supplemental encircling SB is still debatable. Some authors claim that an additional buckling element could improve surgical results , , but others report that with meticulous cleaning of the vitreous base, the addition of SB is not necessary or is even harmful , . Pournaras and Kapetanios compared PPV and PPV plus SB in pseudophakic RDs and found no statistical difference between the two techniques  . A meta-analysis of pseudophakic RD repair found no statistically significant difference between PPV and PPV plus SB groups in the initial and final reattachment rates  .
In our series, SSAS was achieved in 92.9% of the PPV group and in 94.6% of the PPV plus SB group for phakic patients, whereas it was achieved in 94.8% of the PPV group and in 95% of the PPV plus SB group for aphakic/pseudophakic patients. Overall, the reattachment rates were similar and were independent of the lens status at presentation. These results are better than those reported in the scleral buckling versus primary vitrectomy in the RRD study, in which SSAS was achieved in 64 and 53% with PPV in phakic and pseudophakic patients, respectively  . In that study, the addition of SB did not decrease redetachment rates in the phakic group, but did so in the pseudophakic group (41% without SB vs. 11% with SB). Other studies have reported SSAS rates similar to or higher than those obtained in our series with PPV and PPV plus SB: 89 and 73%  , 93 and 94%  , and even 98 and 92%, respectively  . The final reattachment rates were excellent with both techniques in our series: 100% in the PPV group and 98.2% in the PPV plus SB group for phakic patients, whereas it was 97.4% in the PPV group and 100% in the PPV plus SB group for aphakic/pseudophakic patients. However, Sachin and colleagues reported that, of the 37 phakic eyes that underwent PPV alone, 31 (83.8%) achieved SSAS. Of the 68 phakic eyes that underwent combined PPV/SB, 66 (97.1%) experienced successful single-surgery reattachment. Among pseudophakic eyes, 42 of 48 (87.5%) in the PPV group and 62 of 66 (93.9%) in the PPV/SB group remained reattached after a single surgery. The final reattachment rates were excellent with both techniques in our series: 100% in the PPV group and 98.2% in the PPV plus SB group for phakic patients, whereas it was 97.4% in the PPV group and 100% in the PPV plus SB group for aphakic/pseudophakic patients. The final reattachment rates were 100% in both surgical groups, irrespective of phakic status  . This is in disagreement with Martinez-Castillo et al.  , who reported that primary vitrectomy in combination with scleral buckling led to a marked decrease in the primary failure rate and improvement in functional results in RD surgery.
In terms of VA outcome in PPV versus PPV plus SB, the trial by Weichel et al.  for pseudophakic RD reported VA of 20/40 or better in 72% of the patients in the PPV group compared with only 42% of the patients in the PPV plus SB group. However, other trials reported VA improvement by three lines or more in 60% of the patients in the PPV group and in 69% of the patients in the PPV plus SB group  . In this study, postoperative BCVA of 20/40 or better was achieved in five (5.3%) of the PPV eyes and in two (2.7%) of the PPV plus SB eyes. The mean final VA was also better in the PPV group: 0.17 ± 0.12 decimal versus 0.1 ± 0.09 decimal in the PPV plus SB group. This is lower than the result of Kinori and colleagues; they found that postoperative VA of 20/40 or better was achieved in 62.5% of the PPV eyes and in 47% of the PPV plus SB eyes. The mean final VA was also better in the PPV group: 0.41 logarithm of the minimal angle of resolution units (20/51) versus 0.53 logarithm of the minimal angle of resolution units (20/68) in the PPV plus SB group  .
The rate of SSAS was independent of tear location in this series. The break location in successful single-surgery cases in group I was superior in 49/52 eyes (94.2%), inferior in 23/23 eyes (100%), superior and inferior in 16/18 eyes (88.9%), and unidentified in 1/2 eye (50%), whereas in group II, it was superior in 41/42 eyes (97.6%), inferior in 18/20 eyes (90%), superior and inferior in 9/9 eyes (100%), and unidentified in 3/4 eyes (75%). There was no statistically significant difference between two groups in the relation between tear location and SSAS, except in patients showing unidentified break. This was similar to the result of Kinori et al.  , who reported that RRDs from inferior breaks had the same anatomic outcome as RRD with superior breaks (85.1 and 81.2% for PPV and PPV plus SB groups, respectively.
In terms of the method and the pattern of retinopexy, in our study, 360 laser retinopexy led to SSAS in 55 from 60 patients (91.7%) in group I and 43 from 47 patients in group II (91.5%), laser only around breaks led to SSAS in 31 from 32 patients in group I (96.9%) and 27 from 27 patients in group II (100%), and cryopexy led to 100% success in both groups. Campo et al.  reported that PPV and 360° peripheral endophotocoagulation without scleral buckling in eyes with pseudophakic RD achieved a reattachment rate of 88% in one operation and 96% with repeated procedures. Whether or not this type of endophotocoagulation can substitute the use of scleral buckling needs further studies. In our series, the 360° laser retinopexy does not yield better results than laser only around breaks in successful single-surgery cases in both groups.
Postoperative PVR is the most serious complication after RD surgery and has been reported to occur in 0-19% of eyes after PPV for RRD  . Wickham et al.  found that PVR was more common with the PPV plus SB approach than with PPV alone in RRD with inferior breaks. In this study, as expected, PVR was the leading cause of redetachment: 50% of redetachments in both the PPV group and the PPV plus SB group. This is in agreement with Kinori et al.  , who reported that PVR was the leading cause of redetachment: 66 and 45% of redetachments in the PPV group and PPV plus SB group, respectively.
| Conclusion|| |
Both surgical procedures (vitrectomy with and without SB) can achieve favorable and comparable anatomic outcomes in the majority of patients in the treatment of RRD. Intraoperative and postoperative complications are similar in the two procedures. VA improved significantly in the group with vitrectomy without SB, which was found to be effective in the repair of the primary RD.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
|1.||D′Amico DJ. Primary retinal detachment. N Engl J Med 2008; 359 :2346-2354. |
|2.||Sharma A, Grigoropoulos V, Williamson TH. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol 2004; 88 :1372-1375. |
|3.||Sodhi A, Leung LS, Do DV, Gower EW, Schein OD, Handa JT. Recent trends in the management of rhegmatogenous retinal detachment. Surv Ophthalmol 2008; 53 :50-67. |
|4.||Tewari HK, Kedar S, Kumar A, Garg SP, Verma LK. Comparison of scleral buckling and pars plana vitrectomy in the management of rhegmatogenous retinal detachment with unseen retinal breaks. Clin Experiment Ophthalmol 2003; 31 :403-407. |
|5.||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 :1376-1379. |
|6.||Brazitikos PD, Androudi S, Christen WG, Stangos NT. Primary pars plana vitrectomy versus scleral buckle surgery for the treatment of pseudophakic retinal detachment: a randomized clinical trial. Retina 2005; 25 :957-964. |
|7.||Arya AV, Emerson JW, Engelbert M, Hagedorn CL, Adelman RA. Surgical management of pseudophakic retinal detachments: a meta-analysis. Ophthalmology 2006; 113 :1724-1733. |
|8.||Heimann H, Bartz-Schmidt KU, Bornfeld N, Weiss C, Hilgers RD, Foerster MH. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. Ophthalmology 2007; 114 :2142-2154. |
|9.||Sharma YR, Karunanithi S, Azad RV, Vohra R, Pal N, Singh DV, Chandra P. Functional and anatomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand 2005; 83 :293-297. |
|10.||Ahmadieh H, Moradian S, Faghihi H, Parvaresh MM, Ghanbari H, Mehryar M. 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 2005; 12 :1421-1429. |
|11.||Le Rouic JF, Behar-Cohen F, Azan F, Bertin S, Bettembourg O, Rumen F, et al. Vitrectomy without scleral buckle versus ab-externo approach for pseudophakic retinal detachment: comparative retrospective study. J Fr Ophthalmol 2002; 25 :240-245. |
|12.||Oshima Y, Yamanishi S, Sawa M, Motokura M, Harino S, Emi K. Two-year follow-up study comparing primary vitrectomy with scleral buckling for macula-off rhegmatogenous retinal detachment. Jpn J Ophthalmol 2000; 44 :538-549. |
|13.||Pastor JC, Fernandez I, Rodriguez de la Rua E, Coco R, Sanabria-Ruiz Colmenares MR, Sánchez-Chicharro D, et al. Surgical outcomes for primary rhegmatogenous retinal detachments in phakic and pseudophakic patients: the Retina 1 Project - Report 2. Br J Ophthalmol 2008; 92 :378-382. |
|14.||Heimann H, Zou X, Jandeck C, Kellner U, Bechrakis NE, Kreusel KM, et al. Primary vitrectomy for rhegmatogenous retinal detachment: an analysis of 512 cases. Graefes Arch Clin Exp Ophthalmol 2006; 244 :69-78. |
|15.||Alexander P, Ang A, Poulson A, Snead MP. Scleral buckling combined with vitrectomy for the management of rhegmatogenous retinal detachment associated with inferior retinal breaks. Eye (Lond) 2008; 22 :200-203. |
|16.||Campo RV, Sipperley JO, Sneed SR, Park DW, Dugel PU, Jacobsen J, Flindall RJ. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Ophthalmology 1999; 106 :1811-1815, discussion 1816. |
|17.||Martinez-Castillo V, Boixadera A, Verdugo A, Garcia-Arumi J. Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position. Ophthalmology 2005; 112 :1222-1226. |
|18.||Weichel ED, Martidis A, Fineman MS, McNamara JA, Park CH, Vander JF, et al. Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment. Ophthalmology 2006; 113 :2033-2040. |
|19.||Stangos AN, Petropoulos IK, Brozou CG, Kapetanios AD, Whatham A, Pournaras CJ. Pars-plana vitrectomy alone vs vitrectomy with scleral buckling for primary rhegmatogenous pseudophakic retinal detachment. Am J Ophthalmol 2004; 138 :952-958. |
|20.||Mehta S, Blinder KJ, Shah GK, Grand MG. Pars plana vitrectomy versus combined pars plana vitrectomy and scleral buckle for primary repair of rhegmatogenous retinal detachment. Can J Ophthalmol 2011; 46 :237-241. |
|21.||Pournaras CJ, Kapetanios AD. Primary vitrectomy for pseudophakic retinal detachment: a prospective non-randomized study. Eur J Ophthalmol 2003; 13 :298-306. |
|22.||Kinori M, Moisseiev E, Shoshany N, Fabian I, Skaat A, Barak A, Loewenstein A, Moisseiev J. Comparison of pars plana vitrectomy with and without scleral buckle for the repair of primary rhegmatogenous retinal detachment. Am J Ophthalmol 2011; 152 :291-297. |
|23.||Heimann H, Bornfeld N, Friedrichs W, Helbig H, Kellner U, Korra A, Foerster 0MH. Primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment. Graefes Arch Clin Exp Ophthalmol 1996; 234 :561-568. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]