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Vitrectomy offers several advantages over other procedures for retinal detachment repair
Retinal detachment, whether rhegmatogenous, exudative/serous or tractional, remains a major sight-threatening event that is commonly encountered in the comprehensive ophthalmologist’s office.
Over a lifetime, including the impact of cataract surgery, as many as one per 300 individuals will develop a retinal detachment. It is estimated that 30,000 Americans require surgical repair of a retinal detachment each year. The presence of axial myopia, typically defined as a refraction more than –6 D or an axial length more than 25 mm, increases the risk of retinal detachment to one in 20, or 5% over a lifetime. The incidence of retinal detachment after cataract surgery with uncomplicated phacoemulsification and posterior chamber lens implantation in a non-axial myope is at most 1%. In the axial myope, this risk is increased to 5% by 5 years.
At a recent European meeting I attended, a well-done study performed in Denmark, where there is virtually no loss to follow-up because all surgical patients are treated in the same health care system, reported that the incidence of retinal detachment in the axial myope was 1% per year, reaching 10% at 10 years after surgery. This is consistent with my experience. One of my residents looked at a series of eyes in which I did uncomplicated phacoemulsification and posterior chamber lens implantation in patients with axial myopia, and my incidence of retinal detachment reached 7% by 7 years after surgery. Joseph Colin in France has reported nearly identical numbers. These data lead me to discourage refractive lens exchange in axial myope patients until they develop some visual loss from cataract.
Significant additional risk factors in my study included male sex, lattice degeneration, posterior capsulotomy and a history of a retinal detachment or retinal tear in either eye. In this small series, the middle-aged male axial myope with an open capsule, lattice degeneration and a history of a retinal tear had a retinal detachment risk approaching 20%. For me, this is a patient to avoid when considering refractive lens exchange.
We all regularly see patients who have an acute onset of flashes and floaters, in many cases associated with a posterior vitreous detachment. The aging eye develops a posterior vitreous detachment in nearly 90% of patients by the age of 90 years. Most evolve without causing a retinal tear, but it is incumbent upon us to look carefully when confronted with this history. Lattice degeneration occurs in 8% of the population but in 40% of retinal detachments. For me, the patient who presents with flashes and floaters and is a male axial myope with lattice degeneration or a history of a retinal break vent in either eye demands a more careful look, a good education about the signs and symptoms of retinal detachment, and in some cases a second examination 6 to 8 weeks later to recheck the retinal periphery.
While it is appropriate to dilate the patient and perform a complete examination of the retinal periphery with indirect ophthalmoscopy, I have learned that a careful dilated slit lamp examination of the vitreous to look for the presence or absence of retinal pigment epithelial cells is extremely valuable. An acute retinal tear is almost universally associated with dispersion of pigment epithelial cells into the anterior vitreous, and if I see these cells, even when I cannot locate a retinal tear on my examination, I refer the patient for consultation to a retina specialist.
The methods of treatment rely on the time-tested principles of finding and closing all the breaks. During my residency training in the intracapsular cataract extraction era, scleral buckle repair with subretinal fluid drainage was the procedure of choice, and in our department, the skills of the retina surgeons and the volume of cases they treated were truly awe-inspiring. The 85% to 90% success rate with this surgical approach has remained static for decades, and with two procedures, anatomical reattachment of the retina can be achieved in 95% of eyes.
While highly effective, scleral buckling is not a minimally invasive procedure, and there is a significant period of morbidity for the patient. Pneumatic retinopexy is the least invasive procedure, but it suffers from a high reoperation rate except in the simpler cases with superior tears. Modern vitrectomy combined with endolaser and intraocular gas, or in complex cases, silicone oil, seems to be the preferred approach by most of the younger surgeons who have trained in the last 10 to 15 years. The success rate is similar, and as I look at my postoperative patients, it is a much less invasive approach than the placement of a scleral buckle. There is less trauma to the muscles, less to no induced refractive error, and a lot less pain and swelling in the early postoperative period. Success rates for the typical patient with a posterior chamber lens in place seem equally good with the less invasive vitrectomy approach, and there is no concern for creating a secondary cataract when the natural lens has already been removed.
Of course, the best vitreoretinal surgeons are expert with all three procedures, and in some cases, a combined approach including a scleral buckle, vitrectomy, endolaser, and intraocular gas or silicone oil is required for a lasting repair. Still, based on my current observations, if I develop or a family member develops a retinal detachment after cataract surgery in the next decade, I plan to opt for the less-invasive vitrectomy-based repair and hope to avoid the more traumatic scleral buckle.