SUPPLEMENTAL SCLERAL BUCKLE IN THE ERA OF SMALL INCISION VITRECTOMY AND WIDE-ANGLE VIEWING SYSTEMS.

PURPOSE: To evaluate trends and outcomes of scleral buckle as adjunct to pars plana vitrectomy for management of retinal detachment. METHODS: Retrospective case series including 300 consecutive cases of retinal detachment that underwent pars plana vitrectomy. The series was divided into three consecutive groups: Group A (first 100 cases), Group B (second 100 cases), and Group C (third 100 cases). RESULTS: Three hundred eyes of 289 patients, mean age 61.0 years, were included in the study. The mean follow-up was 31.3 months for Group A, 28.5 months for Group B, and 12.0 months for Group C (P < 0.001). The baseline mean logarithm of the minimum angle of resolution equivalent was 1.58 for Group A, 1.31 for Group B, and 1.33 for Group C (P = 0.15). Supplemental scleral buckle was performed in 53% of Group A, 35% of Group B, and 17% of Group C (P < 0.001). Single surgery reattachment rate was 93% for Group A, 95% for Group B, and 97% for Group C (P = 0.48). The mean change in logarithm of the minimum angle of resolution equivalent was -0.84 for Group A, -0.81 for Group B, and -0.71 for Group C (P = 0.50). CONCLUSION: The study demonstrates decreasing use of supplemental scleral buckle in the era of small gauge vitrectomy surgery and wide-angle viewing systems while the outcomes remain stable. Selective, less frequent use of supplemental scleral buckle is compatible with good anatomical and visual outcomes.

Novel techniques in scleral buckling.

Scleral buckling is a surgical technique that is employed successfully to treat rhegmatogenous retinal detachments (RRD) for more than 60 years. With the introduction of pars plana vitrectomy (PPV), there is a growing trend towards the use of PPV for treatment of retinal detachment. There is a reluctance to perform scleral buckling (SB) in RRD due to the perceived steep learning curve, declining mastery over indirect ophthalmoscopy, and poor ergonomics associated with SB. In this article, we discuss the surgical challenges and tips to overcome these in four headings: localization of the break, retinopexy, SB, and subretinal fluid (SRF) drainage. Localization of the break can be performed by the use of forceps or illuminated scleral depressor. It can be facilitated by prior drainage of SRF in cases with bullous RRD. Chandelier with wide-angle viewing system can be used for easier localization of break and cryopexy. Sutureless buckling and suprachoroidal buckling are easier and faster alternatives to the conventional technique. Reshaping the silicone segment helps in accommodating the wider circumferential band. Modified needle drainage, laser choroidotomy, and infusion-assisted drainage can make SRF drainage easier and safer. The above techniques and other practical tips have been explained in detail with the illustrations to make the process of learning the art of SB easier.

Desprendimiento de retina por intrusión escleral de hilo de Arruga. Tratamiento / Retinal detachment caused by Arruga suture scleral intrusion. Treatment

CASO CLÍNICO: Presentamos el caso clínico de un hombre de 81 años de edad con un desprendimiento de retina causado por la intrusión de un hilo de Arruga. El explante circular se encontraba en el espacio subretiniano y provocaba un desprendimiento de retina con roturas retinianas. DISCUSIÓN: Se realizó una vitrectomía pars plana con sección intraocular del hilo de Arruga con la que se consiguió la reaplicación retiniana

CASE REPORT: We present the case of an 81 year-old man with retinal detachment caused by intrusion of an Arruga suture. The encircling buckle was located in the sub-retinal space and caused retinal breaks with retinal detachment. DISCUSSION: A pars plana vitrectomy was performed along with intraocular cutting of the Arruga suture with retinal re-attachment

Reoperation for rhegmatogenous retinal detachment as quality indicator for disease management: a register study.

PURPOSE: To establish a quality indicator that could be used in optimizing treatment for rhegmatogenous retinal detachment (RRD). METHODS: The Danish National Patient Registry was used to identify surgery conducted in Denmark for RRD in the period 01 January 2001-31 December 2009. Cases were identified by diagnosis and surgical codes. RESULTS: A total of 6522 cases were operated for a primary RRD in the study period, and 22% (1434 patients) were reoperated for a redetachment. A Cox regression analysis showed that the risk of redetachment was equal to or less than detachment on the fellow eye 1 year after primary surgery with techniques not using silicone oil. The same was true 1.5 years after surgery for techniques using silicone oil. Based on this, we established a quality indicator defining failure as the need for operation for redetachment within 1 year from initial surgery when using techniques without oil and after 1.5 years for techniques using oil. Also the lack of oil removal within 1 year from initial surgery should be noted as an operational failure. We applied the quality indicators on the cohort of 6522 RRDs and found that in Denmark the need for redetachment surgery has decreased over time and also that high-volume departments have better outcome compared to smaller ones. CONCLUSIONS: The risk of reoperation for redetachment after initial surgery fulfils the criteria for a good quality indicator and can be used in RRD surgery. This indicator could aid in optimizing the management of RRD patients to minimize morbidity.

Changing trends in surgery for retinal detachment in Korea.

PURPOSE: To analyze trends in rhegmatogenous retinal detachment (RRD) surgery among the members of the Korean Retina Society from 2001 to 2013. METHODS: In 2013, surveys were conducted by email and post to investigate the current practice patterns regarding RRD treatment. Questions included how surgeons would manage six cases of hypothetical RRD. Results were compared to those reported in 2001. RESULTS: A total of 133 members (60.7%) in 2013 and 46 members(79.3%) in 2001 responded to the survey. Preference for pneumatic retinopexy has decreased in uncomplicated primary RRD (p = 0.004). More respondents in 2013 selected vitrectomy as the primary procedure when mild vitreous hemorrhage (p = 0.001), myopia (p = 0.044) and history of successful scleral buckling on the fellow eye (p = 0.044) were added to the primary scenario. Vitrectomy was over twice as popular in cases of pseudophakic, macula-off RRD with posterior capsular opacity (p = 0.001). CONCLUSIONS: For RRD with myopia, pseudophakia and media opacity, surgical interventions over the last decade have drastically shifted from scleral buckling and pneumatic retinopexy to vitrectomy.

Trends and factors related to outcomes for primary rhegmatogenous retinal detachment surgery in a large asian tertiary eye center.

PURPOSE: To describe trends and outcomes of vitreoretinal surgery for primary rhegmatogenous retinal detachment in a large Asian tertiary eye center. METHODS: Retrospective review of 1,530 eyes with primary retinal detachment between 2005 and 2011 managed at the Singapore National Eye Center by one of the following: scleral buckling (SB), pars plana vitrectomy (PPV), and combined SB and PPV (SB + PPV). Anatomical and functional outcomes were assessed. RESULTS: There was a trend toward PPV and PPV + SB as the primary reattachment procedure from 2005 to 2011. The primary anatomical success rate for PPV (78.6%) was worse than that for SB (88.8%) or SB + PPV (89.0%, P = 0.000). Final anatomical success rates were similar for all 3 procedures: SB 97.7%, PPV 95.2%, and SB + PPV 96.4%. Better functional success was achieved in the SB group (86.1%) than both the PPV (72.5%) and SB + PPV groups (77.5%, P = 0.000), partly attributable to the less complex nature of retinal detachments in the SB group. Older age and proliferative vitreoretinopathy were related to the poor functional outcomes in both phakic and pseudophakic eyes. CONCLUSION: There was an increasing trend toward PPV and PPV + SB as the primary retinal reattachment surgery from 2005 through to 2011. High rates of anatomical and functional outcomes were achieved with SB, PPV, and SB + PPV, proliferative vitreoretinopathy and older age were negatively correlated with the functional success in both phakic and pseudophakic eyes.

Changing Trends in Surgery for Retinal Detachment in Korea

PURPOSE: To analyze trends in rhegmatogenous retinal detachment (RRD) surgery among the members of the Korean Retina Society from 2001 to 2013. METHODS: In 2013, surveys were conducted by email and post to investigate the current practice patterns regarding RRD treatment. Questions included how surgeons would manage six cases of hypothetical RRD. Results were compared to those reported in 2001. RESULTS: A total of 133 members (60.7%) in 2013 and 46 members(79.3%) in 2001 responded to the survey. Preference for pneumatic retinopexy has decreased in uncomplicated primary RRD (p = 0.004). More respondents in 2013 selected vitrectomy as the primary procedure when mild vitreous hemorrhage (p = 0.001), myopia (p = 0.044) and history of successful scleral buckling on the fellow eye (p = 0.044) were added to the primary scenario. Vitrectomy was over twice as popular in cases of pseudophakic, macula-off RRD with posterior capsular opacity (p = 0.001). CONCLUSIONS: For RRD with myopia, pseudophakia and media opacity, surgical interventions over the last decade have drastically shifted from scleral buckling and pneumatic retinopexy to vitrectomy.

Trends in primary retinal detachment surgery: results of a Bicenter study.

PURPOSE: To assess trends and outcomes in retinal detachment (RD) surgery based on a retrospective, interventional, bicenter study. METHODS: Baseline demographic data, surgical procedures, and outcomes from 230 patients with a diagnosis of primary rhegmatogenous RD, who underwent surgery between January 2007 and December 2008 at the Rudolf Foundation Clinic, Vienna (Center 1) and the Weill Cornell Medical College, New York, (Center 2) were analyzed using a regression model. RESULTS: Besides the baseline parameters, lens status (P = 0.01), refraction (P = 0.01), retinal tears (P < 0.02), proliferative vitreoretinopathy (P = 0.02), and previous treatment (P < 0.02), the primary RD procedure (P < 0.0001) was significantly different between the 2 centers. In Center 1, scleral buckling was the most common primary RD procedure (66.19%) compared with vitrectomy (82.42%) in Center 2. Primary retinal reattachment (88.49% Center 1 vs. 84.62% Center 2, P = 0.43) and best-corrected visual acuity at the final follow-up (best-corrected visual acuity ≥ 0.3 logarithm of minimum angle of resolution 48.92% Center 1 vs. 47.25% Center 2, P = 0.78) were not significantly different between the 2 centers. CONCLUSION: Although there is a trend toward primary vitrectomy, scleral buckling was preferred in the center in Vienna and primary vitrectomy in the center in New York. Despite the different primary RD procedures, anatomical and visual outcomes were comparable.

Use of retinal procedures in medicare beneficiaries from 1997 to 2007.

OBJECTIVE: To observe how the treatment of retinal conditions changed over the preceding decade. METHODS: Medicare fee-for-service data claims filed between 1997 and 2007 were analyzed. RESULTS: Fewer than 5000 intravitreal injections of a pharmacological agent were performed annually between 1997 and 2001. Thereafter, the annual number of intravitreal injections more than doubled every year through 2006, reaching a high of 812,413 in 2007. Photodynamic therapy procedures decreased 83% from a peak of 133,565 procedures in 2004 to 22,675 procedures in 2007, while laser treatment of choroidal lesions or neovascularization decreased 83% from a peak of 82,089 in 1999 to a minimum of 13,821 in 2007. Vitrectomies for primary retinal detachment (with or without scleral buckling) increased 72% over the study period from 11,212 in 1997 to 19,923 in 2007, while scleral buckles performed without vitrectomy decreased 69% from 8691 to 2660. Substantial volume increases were also observed for vitrectomy with retinal membrane stripping (90% increase from 29,426 in 1997 to 56,051 in 2007) or endolaser panretinal photocoagulation (86% increase from 10,319 in 1997 to 19,154 in 2007). Volumes of pneumatic retinopexy, laser prophylaxis for retinal detachment, laser treatment for retinal edema, and laser treatment for retinopathy all changed less than 25% from 1997 and 2007. CONCLUSIONS: Marked changes in the use of several retinal procedures occurred between 1997 and 2007, particularly in the treatment of macular degeneration and retinal detachment. These changes point to greater acceptance and incorporation of vitrectomy and intravitreal injection as treatment modalities.

Surgical techniques for repair of primary retinal detachment: Part II. Comparison of present techniques in relation to morbidity.

PURPOSE: To compare present surgical techniques for repair of primary retinal detachment. AIM of each technique is closing the retinal break(s), but the approach is either extraocular (e.o.) with scleral buckling or intraocular (i.o.) with pneumatic retinopexy or vitrectomy. The results are similar ranging between 94% and 99% attachment, however, the difference lies in their morbidity and socioeconomic implications which will be compared. MATERIAL AND METHODS: Literature of cerclage, minimal segmental buckling, pneumatic retinopexy and primary vitrectomy are reviewed for anatomical results, postoperative PVR, new breaks, reoperation and secondary complications jeopardizing regained visual acuity. RESULTS: All 4 surgical approaches for repair of a primary retinal detachment, i.e., e.o. or i.o. procedures, have one common premise for sustained success: To find and close the break(s). This is so whether the surgery is limited to the break or extending over the entire detachment or whether it is performed as an e.o. or i.o. procedure. At present the i.o. procedures still harbour a 6-fold higher risk of postoperative PVR and 2.5-fold of reoperation. The recent SPR Study confirms that in a phakic eye postoperative visual function is statistically significant better after scleral buckling than after primary vitrectomy. CONCLUSION: Since the results after the 4 major techniques for reattaching the retina are similar, therefore, the selected procedure has to fulfill 4 postulates: (1) Retinal attachment with 1 operation, (2) it should harbour a minimum of morbidity, (3) be performed on a small budget and under local anesthesia, (4) it should provide long-term visual function, not jeopardized by secondary complications.

Trends and outcomes of treatment for primary rhegmatogenous retinal detachment: a 9-year nationwide population-based study.

PURPOSE: To determine the trends and outcomes for treating primary rhegmatogenous retinal detachment (RRD) in a nationwide population-based study in Taiwan. METHODS: We collected admission data during the period of 1997-2005, from the Taiwan National Health Insurance Research Database, a source that covers over 96% of Taiwan's 23 million citizens. Totally 28 911 patients with a first-time admission diagnosis of RRD (ICD-9-CM codes 361 to 361.07) and undergoing surgical treatment (scleral buckling (SB), pars plana vitrectomy (PPV), or their combination) were identified. The utilized operation type, 180-day readmission rate for recurrent retinal detachment, length of hospital stay, and admission charge were obtained. Contingency table/chi (2) test and t-test were employed for the statistical analysis. RESULTS: Primary PPV (with or without SB) was a primary procedure in 47.3% of cases in 1997. This rate rose significantly to 61.2% in 2005. A significant decrease in the total 180-day readmission rate occurred from 18.95% in 1997 to 13.81% in 2005. These rates also significantly decreased for each surgical modality (from 16.30 to 11.38% for SB, from 21.29 to 14.69% for PPV, and from 22.99 to 16.55% for PPV+SB). The length of hospital stay decreased for each surgical modality between 1997 and 2005. CONCLUSIONS: There was a significant trend towards more frequently employing primary PPV (with or without SB) for the management of primary RRD. In addition, significant improvements in the primary success rates were shown for each surgical modality group and for total samples between 1997 and 2005.

Recent trends in the management of rhegmatogenous retinal detachment.

It has been nearly a century since Jules Gonin performed the first intervention for rhegmatogenous retinal detachment, trans-scleral cautery, achieving successful outcomes in close to 50% of his cases. With the introduction of alternative surgical approaches in the last half-century, including Charles Schepens' scleral buckle technique and Robert Machemer's pars plana vitrectomy, the surgical success rates have risen to close to 90%. Nonetheless, despite dramatic progress in the success of reattachment surgeries, reasonable disagreement exists as to which approach (or combination of approaches) is the best form of surgical intervention for patients with rhegmatogenous retinal detachments. In this review, the authors summarize the current knowledge of retinal detachment, and examine emerging results from the first large scale, prospective, randomized, controlled clinical trials addressing the efficacy of these surgical approaches for retinal detachment, with the hope of identifying the most appropriate (evidence-based) therapeutic intervention for the treatment of rhegmatogenous retinal detachment.

[Treatment of primary retinal detachment. Minimal extraocular or intraocular?]. / Die Behandlung der primären Ablatio retinae. Minimal extraokular oder intraokular?

The developments in treatment modalities for a primary retinal detachment over the last 70 years have been reviewed. There was a change from a surgery limited to the area of the break to a form of prophylactic surgery including the extent of the detachment. In between Rosengren had limited the treatment to the break with an intraocular gas bubble. A change was brought about by Custodis in 1953 who limited surgery to the break and omitted drainage. This procedure had serious postoperative complications which were eliminated by Lincoff by developing the cryosurgical detachment operation which was subsequently refined to extraocular minimal surgery. The ultimate realization of a minimal extraocular approach was the operation with a temporary balloon. Two additional intraocular procedures evolved, pneumatic retinopexy and primary vitrectomy, following one or the other pattern of treatment. With all four methods reattachment can result in 94-99% of the cases but differences can be seen in the morbidity and rate of reoperations.