The Outcome Of 23 Gauge Pars Plana Vitrectomy Without Scleral Buckle For Management Of Rhegmatogenous Retinal Detachment. By:

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1 The Outcome Of 23 Gauge Pars Plana Vitrectomy Without Scleral Buckle For Management Of Rhegmatogenous Retinal Detachment. By: Mohamed El-Deeb, MD, M.Sc, ICO, FRCS. Vitreoretinal Consultant, Magrabi Eye Center, Riyadh, KSA. Ain Shams University, Egypt. INTRODUCTION It has been nearly a century since Jules Gonin performed the first intervention for rhegmatogenous retinal detachment (RRD), trans-scleral cautery, achieving successful outcomes close to 50% of his cases. In the last half century, new approaches was introduced: scleral buckle and pars plana vitrectomy which improved the success rate of reattachment surgeries to close to 90%. With the innovation of new techniques, the debate exists to which approach (or combination of approaches) is the best form of surgical intervention for RRD. 1

2 INTRODUCTION Despite dramatic improvement in vitrectomy machines and techniques, no radical vitrectomy can be achieved. So, many surgeons believe in the importance of supplementary buckle to support the vitreous base and lower breaks. In the last few years, small gauge vitrectomy (23, 25) became increasingly popular and is replacing the standard 20 g vitrectomy. For those who are believing in supplementary buckle, What are we going to do???? Shall we continue our routine or let s try the new fashion?? Aim Of The Work To evaluate the effectiveness of 23 gauge pars plana vitrectomy (PPV) alone for management of rhegmatogenous retinal detachment (RRD). DESIGN: Retrospective, nonrandomized, interventional case series. 2

3 PATIENTS & METHODS 27 eyes of 26 patients who underwent 1ry 23 guage vitrectomy for Rhegmatogenous Retinal Detachment (RRD) were followed up for at least 3 months after the last surgery. Cases with inferior breaks (defined as those breaks found between 4 & 8 o clock positions) were identified. Patients with PVR worse than grade C1 were excluded from the study. Main outcome measures were: 1- The final visual acuity (VA). 2- Number of surgeries needed for anatomical success. 3- Complications. Preoperative Data 1- Age: Range: (19 70) Mean ± SD: ± Description of Age in the Study > % <20 1 4% % % 3

4 Preoperative Data 2- Sex: Description of Sex in the Study Female: 8 30% Male: 19 70% Preoperative Data 2- BCVA: Pre Operative VA No of Pts < 20/400 20/150-20/400 20/50-20/100 20/20-20/40 4

5 Preoperative Data 3- Lens Status: Pseudophakic 10 37% Aphakic 1 4% Phakic 16 59% Preoperative Data 4- IOP: Ranged from 7 to 20 mmhg. Mean: 12.6 ± 3.4 mmhg. 2 patients (7.4%) were using antiglaucoma drops. 5- Ant. Segment Evaluation: LASIK: 3 patients (11.1 %). Corneal Opacity: 2 patients (7.4 %). Cataract: 3 patients (11.1 %). Pseudophakia: 10 patients (37.04%) Aphakia: 1 patient (3.7 %) 5

6 Retinal Deatachment Description 1- Macula On: 9 Pts. (33.3 %). 2- Average No of Detached Quadrants: Average no of breaks: Non Visible Breaks (preoperatively): 8 Pts. (29 %). 5- PVR : 8 (29.6%). Grade A: 4 Pts. Grade B: 2 Pts. Grade C1: 2 Pts. 6-Pts With Inferior Breaks (Bet 4 & 8 O clock): 10 Pts. (37%). Retinal Deatachment Description 7- Special Forms of RD & Aggrevating Data: Bullous RD: 5 Giant Tear RD: 1 Macular Hole: 3 Vitreous Hge.: 1 Choroidal Detachment: 1 6

7 Surgical Technique All patients in both groups underwent a standard 3-port 23- gauge vitrectomy with 360 of vitreous base shaving under scleral depression using a noncontact wide-angle viewing system (BIOM) combined with an image inverter. All surgeries are done by the same surgeon in the same center (Magrabi Eye Center in Riyadh). Surgical Details 1- Anesthesia: GA 3 Pts., Peribulbar LA with IV sedation 24 Pts. (88.9%) 2- Encircling Buckle: NO Pts 3- Combined with Phaco: 14 pts. of the 16 phakic pts. 4- Posterior Hyaloidal Detachment: if not already present, was created using aspiration with the vitrectomy probe. In some cases, the posterior hyaloid was strongly adherent and microforceps was used to induce PH separation. 5- ILM Peeling: 2 cases (with MH). 6- PFCL Use: 25 pts.(92.6%). 7

8 Surgical Details 7- Vitreous Base Shaving: 360 degrees VB shaving under scleral depression was done in ALL cases. 8- Endolaser Photocoagulation: Done around the tears and completed as 360 degrees in ALL cases. 9- Tamponed: Type of Tamponad SO SF6 25% 3 SO SO Surgical Details 8- Per-Operative Complications: Iatrogenic Breaks: 9 cases. Cataract: 2 cases Escape of PFCL under the retina: 2 cases Trocar & Light Probe below the retina: 1 case 8

9 RESULTS 1-Visual Acuity: It was assessed 1.5 month after 1 st surgery (1ry Results). Then reassessed finally 1.5 months after the 2 nd surgery if needed. RESULTS 1ry results showed that 5 pts. (17.24%) achieved better than 20/40, 17 pts. (62.96%) achieved better than 20/100, 26 pts (96.3%) achieved better than 20/400 Post Operative VA (1ry Results) No of Pts < 20/400 20/150-20/400 20/50-20/100 20/20-20/40 9

10 RESULTS Final BCVA showed that 12 pts. (44.44%) achieved better than 20/40, 21 pts. (77.78%) achieved better than 20/100, 26 pts (96.3%) achieved better than 20/400 Final BCVA No of Pts < 20/400 20/150-20/400 20/50-20/100 20/20-20/40 RESULTS Comparison of BCVA at Different Stages of the Study < 20/400 20/150-20/400 20/50-20/100 20/20-20/40 Pre Op BCVA 1ry Post Op BCVA Final BCVA 10

11 RESULTS 2- Number of Surgeries Needed for Anatomical Success: Anatomical success was achieved in all cases from the 1 st surgery. 2 nd surgery was needed only for those whose silicon oil as tamponad. Average time of Silicon Oil Removal: 2.94 months. Finally: 24 cases achieved complete anatomical success. 1 case with faint macular pucker In 2 cases there was lower localized peripheral RD limited by the intraoperative 360 degrees laser barrage. Both were stable during the follow up period. RESULTS 3- Complications: A- Per-Operative Complications: Iatrogenic Breaks: 9 cases. Cataract: 2 cases Escape of PFCL under the retina: 2 cases Trocar & Light Probe below the retina: 1 case. 11

12 RESULTS 3- Complications: B- Post Operative Complications: Macular pucker: 1 case Localized peripheral RD: 2 cases. 2ry Glaucoma: 3 new Pts. developed high IOP which was controlled by medications. 1- Bullous RD ( Pre Op) 12

13 1- Bullous RD ( Pre Op) 1- Bullous RD ( Post Op) 13

14 1- Giant Tear RD 1- Giant Tear RD 14

15 1- Horse Shoe tear (Pre Op) 1- Horse Shoe tear (Pre Op) 15

16 1- Horse Shoe tear (Post Op) 1- RD with Myopic MH (Pre Op) 16

17 1- RD with Myopic MH ( with silicon oil) 1- RD with Myopic MH (after silicon oil removal) 17

18 ILM Peeling in RRD With MH Escape of PFC Under The Retina 18

19 CONCLUSION 1ry 23 gauge pars plana vitrectomy (PPV) alone is an effective and safe surgical approach for management of rhegmatogenous retinal detachment (RRD). The smaller port and the new improvements in vitrectomy machines enables safe shaving of the vitreous base which is crucial for surgical success. Laser 360 degrees is protective against redetachment PTK 38 19