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Scleral buckling, vitrectomy both useful with appropriate case selection
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Comparisons of scleral buckling and vitrectomy as the first-line treatment of choice for primary rhegmatogenous retinal detachment have been made for some time.
Even now, there is no single procedure with uniform agreement regarding the best method to treat all rhegmatogenous retinal detachment (RRD) cases because there are a variety of factors that will affect the surgical outcomes of each procedure.
Therefore, I believe both procedures are important and should be mastered, even though retinal fellows currently have less of a chance to learn buckling techniques.
For patients between the ages of 40 and 50 years, I always discuss the benefits and disadvantages of each procedure thoroughly. I let them choose the surgical procedure they would like to have because there is no single procedure seen as the best method to treat all RRD cases. Customizing the surgical procedures and the informed consent obtained from each patient, which depends on age, lens status, condition and duration of the retinal detachment, and whether it involves the macula on or off, is important in choosing buckling or primary vitrectomy as the best first-line procedure for primary RRDs.
Younger patients
I prefer to use scleral buckling for treating patients younger than 40 years whenever possible because almost all RRDs in younger patients are slowly advanced and often attributed to lattice holes with a strongly attached vitreous or ora dialysis due to trauma. Even though a RRD accompanied by extensive subretinal strands suggests it is long-standing, such cases can be successfully treated with buckling.
However, if young patients have bullous RRDs from multiple tears at different locations and strong vitreous tractions following posterior vitreous detachment, which is a special situation that can be seen in myopic patients, or if patients failed to have the retina reattached with primary buckling to treat unknown holes, they can rationally undergo lens-sparing vitrectomy as a revision.
For scleral buckling, I use a microsurgery approach in conjunction with an indirect microscope. I like to perform external drainage in cases with macular-involved RRDs under the microscope to avoid bleeding complications and cryoretinopexy with scleral indentation under the indirect microscopic examination. Recently, I shifted to performing scleral buckling entirely under the surgical microscope by using a wide-angle viewing system in combination with a slit illumination built in to the microscope or a chandelier endoilluminator. Under the surgical microscopic examination, we can more easily find the holes that were unknown before surgery or not located using a conventional indirect microscope during surgery. Buckling is an elegant surgical technique with many variations and considered a safer technique than vitrectomy. However, caution should be taken because inappropriate indications and poor procedures can not only lead to surgical failure, but also to serious complications such as increasing refractive errors, ocular circulation disturbance or impairment of eye movements after surgery.
Older patients
For most patients older than 50 years, retinal breaks are caused by vitreous traction associated with posterior vitreous detachment. In these patients, I prefer to use buckling as the first-line treatment for simple cases, such as those with a single tear or multiple tears that are localized within one or two quadrants, even if mild proliferative changes or severe pigment dispersion has occurred. These cases can easily be treated with a segmental buckle with a short surgical time, fewer complications and early recovery. Other than these simple cases, I have a higher chance of performing primary vitrectomy.
I use a 25-gauge system with a transconjunctival approach in almost 100% of primary retinal detachment cases. Primary vitrectomy has been seen as a potential high-risk, high-return surgical procedure for retinal detachment in the past. However, thanks to the better understanding of vitreoretinal pathologies and the recent evolution of surgical technologies and techniques, more experienced surgeons have started to drift toward using vitrectomy for primary RRDs.
The key for achieving anatomical success with primary vitrectomy is to extensively remove/relieve the vitreous adhesion up to as far as the periphery. This might be the reason for the higher surgical success in pseudophakic RRDs because of the easy access to the periphery without the concern of touching the crystalline lens. Even in cases with inferior breaks, we can achieve similar surgical success rates as compared with those with retinal breaks localized at the superior regions by performing extensive vitreous shaving up to the periphery without combining any buckles.
Postop complications
Cataract progression is one of the well-known post-vitrectomy complications that lead to secondary visual disturbance. In patients older than 50 years, the chance to have post-vitrectomy cataract will reach 80% within 2 years. In Japan, this will not be a barrier to using vitrectomy for primary RRDs if vitrectomy is considered to have a higher initial success rate with lower side effects in selected cases.
We prefer to perform phacoemulsification-vitrectomy with simultaneous IOL implantation and gas tamponade in phakic eyes instead of combining buckles and sparing the lens. In many countries other than Japan, this will sometimes be considered over-treatment.
However, because of the long history of performing phaco-vitrectomy with IOL implantation in a variety of vitreoretinal diseases, many Japanese retina specialists are familiar with phaco techniques and have obtained favorable surgical results. Currently, the initial success rates of phaco-vitrectomy without combining with buckles for treating primary RRDs are reported around 90% to 95%. The final success rate has been from 99% to 100% in most studies in Japan. Although the studies are not randomized and most surgeries are performed by experienced surgeons, the surgical results reported here are much better than the data reported in the Scleral Buckling vs. Primary Vitrectomy in Rhegmatogenous Retinal Detachment (SPR) study, which is the only currently available prospective randomized multicenter study.
Proliferative vitreoretinopathy is the most serious and concerning postoperative complication after vitrectomy for primary RRD. The reason for this complication is not attributed to primary vitrectomy but to insufficient vitreous shaving during the vitrectomy. Once extensive vitreous shaving is achieved, this procedure can be more easily accomplished in pseudophakic eyes or in phaco-vitrectomy, and we will have a lower chance to encounter proliferative vitreoretinopathy situations even if retinal redetachment occurs.
The intervals of postoperative examinations may also account for the incidence of proliferative vitreoretinopathy. Once vitreous traction to the retinal breaks has been relieved and vitreous shaving performed to thin the remaining vitreous at the periphery, retinal redetachment after long-standing retinal reattachment is theoretically rare in cases treated with vitrectomy. This is because the traction to the original breaks has been relieved and the remaining thinner vitreous bed around the periphery will not have enough force to create new breaks. The only possibility to account for the retinal redetachment will be the reopening of the original breaks soon after tamponade gas has been absorbed, possibly because the original breaks were not treated well by laser or cryoretinopexy during the initial surgery. Therefore, at least in my cases, most retinal redetachments have been found soon after the absorption of tamponade gas. Close examinations postoperatively, within 1 month to 2 months after the tamponade gas is absorbed, are important and helpful in detecting the possibility of early retinal reopening or focal retinal redetachments for timely revision.
In conclusion, both scleral buckling and vitrectomy are useful procedures for primary RRDs with appropriate case selection.
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For more information:
Yusuke Oshima, MD, PhD, is associate professor, Department of Ophthalmology, Osaka University Graduate School of Medicine, and director of the vitreoretinal division at the Tianjin Eye Hospital, Tianjin, China. He can be reached at 2-2 Yamadaoka (Room E7), Suita 565-0871, Japan; +81-6-6879-3456; fax: +81-6-6879-3458; email: yusukeoshima@gmail.com.
Disclosure: Dr. Oshima is an international board member of Alcon Laboratories and a consultant to Topcon Medical Laser Systems and Synergetics. He has no proprietary interests or royalties relevant to this article.