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

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