Vitrectomy gaining popularity in rhegmatogenous retinal detachment management

Donald J. D’Amico

Vitrectomy as a treatment for rhegmatogenous retinal detachment has gained increasing popularity in recent years.

“According to Medicare data, approximately 80% more vitrectomies are performed now compared to 1997, while scleral buckling, which used to be the gold standard, is down by 70%,” Donald J. D’Amico, MD, Bietti Medal Lecturer at the annual joint meeting of Ocular Surgery News and the Italian Society of Ophthalmology in Rome, said.

Pneumatic retinopexy is another alternative also on the rise (up 23%) but is suitable for only specific cases and very cooperative patients.

Three techniques

Rhegmatogenous retinal detachment is still an important cause of visual loss worldwide. The surgical techniques developed over the last century have increasingly improved the outcomes, but no uniform agreement has been reached on the best method to reattach the retina.

Scleral buckling is an effective method that has not undergone significant changes over the years, Dr. D’Amico said. Success is largely surgeon-related because it is a difficult technique that requires skill and experience at every step, including precisely localizing retinal breaks, passing sutures through the thin sclera, accurately placing the buckle on the sclera and draining subretinal fluids.

Vitrectomy is also an excellent technique for primary retinal detachment, Dr. D’Amico said. In 2008, Mendrinos and colleagues reported comparable results to those obtained after scleral buckling in a prospective series of 100 eyes. There is still controversy on the use of vitrectomy in phakic eyes because of the risk of inducing cataract, which is why most case series include only pseudophakic eyes. However, vitrectomy can be safely performed in many phakic eyes as well, as long as appropriate surgical maneuvers are performed, according to Dr. D’Amico.

“I use a specific technique to avoid trauma to the lens,” he said. “I treat the peripheral retinal breaks with cryotherapy instead of endolaser and can easily visualize the breaks and the instruments I use through the surgical microscope during vitrectomy. In this way, I avoid surgical maneuvers in the peripheral retina with the endolaser probe that may be potentially hazardous to the lens.”

Recently, Dr. D’Amico’s group at Weill Cornell Medical College in New York worked with a group led by Susanne Binder, MD, at the University of Vienna to compare results of 230 cases of retinal detachment.

“The Vienna group used scleral buckling in 66% of the cases, while in our group, 88% of the cases were treated by vitrectomy. No significant difference in reattachment rate was found, and final visual acuity was also comparable,” Dr. D’Amico said.

Pneumatic retinopexy was introduced more than 25 years ago and, when it is successful, “is one of the most elegant procedures in retinal surgery,” he said. However, it has limited indications, requires specific conditions and a close collaboration with the patient. Two recent case series have shown a primary success rate between 66% and 75% and a final success rate of 99%.

“Visual acuity results tend to be superior to those of scleral buckling and vitrectomy, because the procedure is minimally invasive and the cases are highly selected,” Dr. D’Amico said.

Surgeon preferences

Dr. D’Amico uses all three techniques, following careful patient selection.

“I use vitrectomy in most cases, with both phakic and aphakic eyes. I use scleral buckling for some detachments with inferior breaks or with many breaks around the periphery, but the number of scleral buckling procedures is progressively decreasing in my practice. I use pneumatic retinopexy in a few cases, if the indications are strictly met and the patient is cooperative and understanding. If the first pneumatic retinopexy fails, I do not perform a subsequent one,” he said.

Vitrectomy is rapidly gaining ground compared to other techniques and is the procedure that most young surgeons use.

“Although scleral buckling has successfully treated thousands of eyes, whether we like it or not, we must come to terms with the reality that young surgeons are no longer performing it,” Dr. D’Amico said. – by Michela Cimberle

References:

• Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Ophthalmology. 1999;106(9):1811-1816.
• Mendrinos E, Dang-Burgener NP, Stangos AN, Sommerhalder J, Pournaras CJ. Primary vitrectomy without scleral buckling for pseudophakic rhegmatogenous retinal detachment. Am J Ophthalmol. 2008;145(6):1063-1070.

• Donald J. D’Amico, MD, can be reached at Weill Cornell Medical College, 1305 York Ave., New York, NY 10021; 646-962-2865; fax 646-962-0600; email: djdamico@med.cornell.edu.
• Disclosure: Dr. D’Amico has no relevant financial disclosures.

As the author said, there are three techniques that can be used for rhegmatogenous retinal detachment. They have specific indications and, ideally, all three should be part of every retinal surgeon’s armamentarium. It is also true that vitrectomy is becoming the new gold standard. Young surgeons do not even engage in the uphill challenge of learning scleral buckling, because small-gauge vitrectomy offers a good, more reproducible alternative with a shorter learning curve. In times of change, the views of opinion leaders such as Dr. D’Amico are crucial in orienting clinical practice. The expanding role of vitrectomy is a fact, and the technique has great potential. I agree with Dr. D’Amico, although I advocate the use of scleral buckling in selected cases. Because I do vitrectomy a lot, I know how deceitfully “simple” it may be and I still prefer buckling whenever possible. There is so much surgeon-to-surgeon variation in these techniques that they will never be comparable in official trials, but we should continue comparing experiences to improve our outcomes.

– Cesare Forlini, MD
Head of Ophthalmology, Civic Hospital, Ravenna, Italy
Disclosure: No products or companies are mentioned that would require financial disclosure.