Scleral buckling effective adjunct to PPV in retinal tears

Study results prompt surgeons to recommend vitrectomy with a buckle in pseudophakic patients and a buckle alone in phakics.

ByJared Schultz

NUREMBERG – Scleral buckling surgery has a place as an adjunct to primary vitrectomy in cases of retinal detachment, according to the results of one study.

Presenting results at the German Ophthalmic Surgeons meeting from a study comparing buckling surgery to primary vitrectomy in more complex retinal detachments, Heinrich Heimann, MD, said the type of procedure to be used depends on whether the patient is phakic or pseudophakic.

The scleral buckling vs. primary vitrectomy in rhegmatogenous retinal detachment (SPR) study was conducted at 25 centers in five European countries to assess the specific advantages of vitrectomy and buckling alone or together, according to Dr. Heimann.

“Buckling still has its place, but vitrectomy is gaining ground. There is also the concept of vitrectomy plus buckling,” Dr. Heimann said. “The basis of the SPR study was to find out whether any of these procedures provides a specific advantage.”

A cohort of 681 patients was recruited for the study, and all had primary retinal detachment of medium severity, according to Dr. Heimann. The patients were separated into two groups for the study, phakic and pseudophakic.

In both groups, the surgeons were randomized to perform either buckle surgery or a primary vitrectomy with or without a buckle, Dr. Heimann said.

“In primary vitrectomy, should we do an additional buckle or not? This was the main controversial issue regarding the study design,” Dr. Heimann said. “For this reason, the surgeon was asked to do his standard procedure with vitrectomy. One group of surgeons always used a buckle and the other group of surgeons never used it. This was the only way to conduct the study.”

Pseudophakic results

The main endpoint in the study was visual acuity improvement, Dr. Heimann said. The results showed no significant differences in the pseudophakic group between those with a buckle and those with a vitrectomy, with the majority of patients in both groups gaining around 6 Snellen lines.

However, Dr. Heimann said they found differences with regard to the surgeons performing the surgeries.

“It depended on which surgeon did the surgery and not the procedure,” he said.

In terms of the actual success of the procedures, Dr. Heimann said primary vitrectomy fared better than buckle surgery, with 70.3% of 111 vitrectomy cases achieving primary success compared to 54.4% of 125 buckle surgery cases. Primary success was defined as retinal detachment without any secondary retina affecting intervention, including additional retinopexy or gas injection.

In a subanalysis comparing primary vitrectomy with a buckle to vitrectomy without, the results showed that patients with the added buckle did much better, Dr. Heimann said. Of 73 patients who had an additional buckle, only 20.5% needed a retina-related reoperation compared with 42.1% in the group without the added buckle.

Phakic results

In contrast to the pseudophakic group, there was no significant difference in lines gained between the two procedures with +0.71 lines for buckling vs. +0.56 lines for vitrectomy. There was no difference between the surgeons either.

“The surgeon did not play a significant role as opposed to the pseudophakic group,” Dr. Heimann said.

The results showed what Dr. Heimann an advantage of buckling due to the differences in visual acuity change and the number of cataract surgeries that needed to be performed in conjunction with the surgery for retinal detachment.

Out of 192 primary vitrectomy patients, 51% needed a cataract operation compared with 18.6% of 194 buckle patients.

“The surgeons were asked to do cataract surgery when they believed it reflected on vision,” Dr. Heimann said.

In the subanalysis between primary vitrectomy with or without a buckle, the results showed no significant difference between the two groups. But when compared with the pseudophakic group, the results showed fewer patients without an additional buckle required a retina-related reoperation in this group.

“The results without the added buckle were even better in the phakic group, and for this reason the tendency for this group was for vitrectomy without the added buckle,” Dr. Heimann said.

Bucking the trend toward vitrectomy

These results go against what Dr. Heimann said has been a steady worldwide trend toward primary vitrectomies alone.

Dr. Heimann referred to the large number of complications associated with buckling surgery that he said has prompted many surgeons to abandon the procedure all together in Asian countries and in North and South America.

In light of these results, however, Dr. Heimann concluded that buckling surgery still has a place.

“In pseudophakic patients … the recommendation is vitrectomy with added buckle. With phakic patients of medium severity, we recommend buckling surgery based on the lower number of cataract surgeries,” Dr. Heimann told attendees. “To answer the initial question of whether buckling surgery is still up to date, we can say more than ever. In Germany, it is by far the most commonly done surgery for retinal detachment, even with medium severity.”

For more information:

Heinrich Heimann, MD, can be reached at St. Paul’s Eye Unit, Royal Liverpool Hospital, Prescot St., Liverpool, L7 8XP, UK; +44-(0)151-706-2000; heinrichheimann@yahoo.de.

Jared Schultz is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses geographically on Europe and the Asia-Pacific region.