TOPIC : REPAIR OF PRIMARY RHEGMATOGENOUS RETINA DETACHMENT , WHICH SURGICAL
TECHNIQUE IS BEST SUITED ?
AUTHOR : OLUFEMI ODERINLO FRCS(Ed), DRCOphth (UK)
CONSULTANT OPHTHALMOLOGIST AND VITREORETINA SURGEON
EYE FOUNDATION HOSPITAL
27 ISAAC JOHN STREET GRA IKEJA
LAGOS. NIGERIA
INTRODUCTION
A Rhegmatogenous retina detachment (RRD) is an ophthalmic emergency , surgical repair should be
instituited as soon as possible to forestall irreversible damage to retina cells. The choice of surgical
technique is very important to ensure primary anatomic success defined as successful anatomic
retina reattachment without need of any futher surgical intervention. Primary anatomic success is
important for good visual outcome and subsequent patient rehabilitation.
Three major surgical techniques are available for repair of RRD, these include sclera buckling
procedure (SB) with or with subretina fluid drainage, pars plana vitrectomy (PPV) with internal
tamponade using either silicon oil or gas and pneumatic retinopexy (PR) which involves the use of
intraocular gas. Surgeon preference, patient presentation and availability of facilities play a big role
in deciding which technique of repair to use.
No two cases of RRD are exactly the same, hence the choice of technique for repair should be
individualized , a full understanding of the merits and demerits of each technique is required. In
order to maintain and probably improve on present anatomic reattachment rates which is between
80 and 95% (1,2,3,4) .We need to thoroughly evaluate every patient before surgery, there is still no
substituite for thorough preoperative evaluation , search for offending breaks and associated
pathology and planning for possible operative complications.
The aim of retina reattachment surgery still includes locating and sealing all retina breaks, relieving
retina traction and bringing the retina and choroid in contact for sufficient time to allow adequate
chorioretina scars to form ,after creating a chorioretina reaction with Laser or cryotherapy.
A few other factors are important and these include
Characteristics of the offending retina break : the size (giant retina tears, large breaks) , location (
macula, periphery , equator or posterior pole), number and type (dialysis, retinoschisis, round ,horse
shoe).
Associated pathology : posterior vitreous detachment (PVD), vitreous hemorrhage and debries and
presence of proliferative vitreoretinopathy (PVR) are equally important considerations .
Below are a few suggestions on techniques for particular RRDs
1. RRD associated with giant retina tear : Giant retina tears (GT)are retina breaks that extend over
90 degrees or more of the retina. RRDs from giant tears have certain peculiarities viz a
tendency to roll over, difficulty with reattachment intraoperatively , difficulty maintaining
reattachment, high risk of posterior slippage during exchange, prolonged surgical time
,tendency to multiple procedures, surgeons skill and experience is important, rapidly
progressive, severe PVR can develop on both surfaces of the retina,hence redetachment surgery
poses a challenge to the surgeon. Most surgeons however prefer PPV techniques for such cases,
the question to use an encircling band or buckle in conjunction with PPV is seen in literature, in
a recent study by Goezinne et al(5) ,they found the absence of use of an encircling sclera buckle
to be associated with redetachment after vitrectomy with internal tamponade for RRDs from
giant tears , this was however not corroborated by Ambresin et al (6) who had good surgical
outcomes without using encircling buckles. Proponents of use of adjoining sclera buckle believe
this will further relieve retina traction and support inferior retina if holes are present ,however
buckles can also worsen the already rolled edges of the tears and constituite additional
procedure specific complications, it also increases operative time and hence requires more
resources. If an offending inferior hole exist a retinotomy and or retinectomy can be done to
join all breaks when close together , a thorough fluid air exchange is important before injecting
silicon oil, 5000cs may be used when longterm tamponade is required. SBs and PRs may not be
effective in the longterm in managing RRDs from giant retina tears .
•
2 RRD from Dialysis : A dialysis is a detachment of the neurosensory retina anterior to the ora
serrata . It is important to differentiate it from a giant tear ,dialysis are 3 times more common than
GTs and dialysis from trauma seen are often seen in superonasal retina quadrant, spontaneous
ones in the inferotemporal . RRDs tend to progress relatively slower than with giant tears and are
less likely to have rolled over edges. Scleral buckles are often successful with dialysis( 7), vitrectomy
is indicated if there are other post traumatic pathologies like vitreous hemorrhage and associated
irregular retina breaks, posterior breaks and significant vitreoretina traction.
3 Pseudophakic retina detachment : Scleral buckling (SB) is an established technique for the
treatment of rhegmatogenous RDs. Recent advances in pars plana vitrectomy (PPV) techniques have
encouraged retinal surgeons to expand the role of vitrectomy in the management of complicated
and uncomplicated pseudophakic RDs. Several published reports compare anatomical outcomes
following different surgical techniques in the management of pseudophakic RDs (8).A recent metaanalysis on the management of uncomplicated pseudophakic RDs revealed anatomical success rates
of 81% following SB, 91% after PPV, and 97% for the combined technique of PPV with SB after a
single surgery. Brazitikos et al conducted a randomized clinical trial and demonstrated a similar
advantage of primary PPV over SB surgery in patients with early pseudophakic RDs (9). The retina was
attached in 83% and 94% in the SB and PPV groups respectively following single surgery. Overall, the
primary surgical success rate following SB varies from 61% to 97% in uncomplicated pseudophakic
RDs, while the comparable anatomical outcome following PPV ranges from 84% to 98%. PPV offers
the advantages of removing posterior capsular opacity, clearing vitreous debris, detecting unseen
breaks, releasing vitreous traction, and removing gliogenic cells without inducing significant changes
in refractive error postoperatively. Application of PPV in pseudophakic RDs is limited by inadequate
endotamponade to inferior breaks , an inferior buckle can sometimes be used to support inferior
breaks. PPV gives better control and satisfaction to remove all vitreous traction which often
associate pseudophakic RD ,on few occasions where no significant traction or PVR occurs , a SB may
be indicated, I now seldom do combined buckles and vitrectomy.
4 RRDs from Macular holes in High Myopes: In the pathogenesis of this type of detachment
different types of vitreoretinal changes create both anterioposterior and tangential tractions
resulting in different types of detachments. Both vitreous traction , sclera and chorioretina
dysfunction play important roles while posterior vitreous detachment and posterior vitreous schisis
are important considerations(10,11) A recent randomized clinical trial evaluated the use of posterior
sclera buckling (PSB), pars plana vitrectomy (PPV)and pneumatic retinopexy (PR) in management
and found slightly lower anatomic success (89%) at first surgeries in the PR group when compared to
the other two (96% and 92%)(12) .PPV offers the advantage of relieving vitreous traction and an
attempt at peeling epiretina membrane and internal limiting membrane to improve macula hole
closure rates.PPV definitely has advantages for this type of detachment.
5 Inferior RRDs : RRD retina detachments involving the inferior hemisphere of the retina with the
offending pathology within this area are quite challenging. SBs or PPV can be used and sometimes a
combination of both. SB are useful in phakic eyes with round hole holes , minimal or no traction and
when no PVR or early PVR of grade B(13) and less is present. PPV with either gas or silicon oil
tamponade offers advantages in RRDs with other associated pathology such as advanced PVR,
vitreous hemorrhage, old detachments and large tears. A Sharma and colleagues in a recent study
(14)
evaluated the use of PPV with intraocular gas tamponade and postoperative positioning in the
management of inferior RRDs. Final anatomic success of 95.8 % was achieved in both the inferior
RRD group and the comparative group which included other types of detachments. They concluded
as follows “This study has shown that acceptable success rates can be achieved using PPV alone to
treat RRD with inferior breaks. Complications are minimised and patients in this high risk group have
an 81% chance of primary success. Pars plana vitrectomy and gas will successfully reattach the
retina and a supplementary SB, to support the inferior retina, is unnecessary as the intraocular gas,
and face up or, right or left side down positioning will tamponade breaks satisfactorily”. Similar
findings were reported by Tanner et al (15). Different heavy tamponades have been evaluated for
surgery in RRDs , most evalauations involve inferior detachment and are said to have theoretical
advantages of better tamponading effects in the inferior retina, however , high complication rates
are reported in the first two generation of these heavy tamponade (16,17). Although the newer
preparations may be safer many surgeons still approach their use with caution. Inferiror
retinectomy with radical anterior vitreous base dissection can be useful in many complicated
cases(18,19).
6 Superior RRDs: PPV, SB or PR may be appropriate in different case scenerios of superior RRDs. A
recent study (20) addressed RRDs with breaks located within 1 clock hours in the superior 2/3rds of
the retina and PVR not exceeding grade B, Scleral buckling was compared with pneumatic
retinopexy with regard to single-operation reattachment (82 versus 73%), reattachment with one
operation and postoperative laser/cryotherapy (84 versus 81%), although the anatomic results of
the two operations were not significantly different (P greater than 0.05), pneumatic retinopexy
had less morbidity and better postoperative visual acuity (P = 0.01). Pneumatic retinopexy is
recommended for cases meeting the admission criteria. PR offers advantages of single operation
reattachment and that sometimes it can be done as an office procedure, however postoperative
evaluation is very important as it has higher rates of missed breaks and limits air travel in the
immediate period. It is also better suited for uncomplicated cases that meet the above criteria (
holes within 1 clock hours in the superior 2/3rds of the retina). PPV offers advantages in more
complex cases and both air and silicon oil are good tampondes for the superior retina . Minimal
Segmental buckles without drainage also have unique advantages as primary procedures in
superior RRDs, there are no intraocular complications (except for a rare choroidal hemorrhage in
about 0.3%).Secondary glaucoma, cataract, intraocular hemorrhage, intraocular infection, retina
incarceration and iatrogenic breaks are almost completely eliminated (21,22,23,24). Saw et al
concluded in their study(25) evaluating various interventions available for RRD as follows
“Pneumatic retinopexy is a possible alternative to scleral buckling in the treatment of
uncomplicated rhegmatogenous retinal detachment. The rates of missed or new retinal breaks
after pneumatic retinopexy, however, are higher than following scleral buckling. The clinical
outcomes of vitrectomy for rhegmatogenous retinal detachment compare favourably”. PPV has
advantages in complex cases and intraocular tamponade with silicon oil is also good for superior
breaks. Superior RRDs definitely have a higher number of options for primary repair.
The African Dilema
Patients with RRDs in African populations often present late with complex pathology, (26,27)
The general expectation is that RRDs with complex pathologies achieve better anatomical results
with PPV, giant tears , advanced PVR, Longstanding RRDs all tend to do better with PPV. The
combined primary success rate of larger consecutive studies with SB in a recent review was 85% ,
compared with a between 75 -91% in PPV as summarized by Wilkinson (28)
These results suggest that more of the cases presenting for surgery in Africa will require PPV,
unpublished data from our department showed we use primary PPVs in 74.8% of RRDs.
Unfortunately equipment for vitrectomy is expensive and only few instituitions in Africa have such
facilities. Facilities for SBs are relatively less expensive and the procedure seemingly less difficult to
learn. Provided early presentation is ensured and less complex pathology, SBs can be done in a large
number of patients with RRD, others should be promptly refered to instituitions with available
facilities.
Tertiary Centres with facilities for PPV should not be too few and regular training and updates
should be encouraged.
JOIN THE DEBATE
SO a twenty five year old apprentice presented with six months history of sudden loss of vision in his
only seeing right eye following trauma during a confrontation with a fellow apprentice ,
examination revealed visual acuities of hand movements OD and No light perception, anterior
segements were essentially normal OD with intraocular pressures of 03mmHg by applanation
tonometry. The left eye was pthisical. Funduscopy OD revealed a rhegmatogenous retina
detachment with a giant macula tear with rolled edges (Figure 1).
What surgical procedure is best suited for SO. What intraoperative precursions should be taken.
Please send your contributions about themanagement of SO or about the above topic to :
olufemi_oderinlo@yahoo.com, I would very much like to know your views. Thank you
Figure 1.
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