SCLERAL BUCKLE SURGERY FOR PRIMARY RETINAL DETACHMENT WITHOUT POSTERIOR VITREOUS DETACHMENT

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1 SCLERAL BUCKLE SURGERY FOR PRIMARY RETINAL DETACHMENT WITHOUT POSTERIOR VITREOUS DETACHMENT JILA NOORI, MD, RICHARD A. BILONICK, PHD, ANDREW W. ELLER, MD Purpose: To present and analyze the anatomical and functional outcomes for scleral buckling (SB) in a group of patients with rhegmatogenous retinal detachment without posterior vitreous detachment. Methods: A total of 244 patients underwent SB from 2005 through 2014 by a single surgeon (A.W.E.). Forty patients (45 eyes) were identified as fulfilling the criteria of presenting with a rhegmatogenous retinal detachment without posterior vitreous detachment. Visual outcomes, preoperative retinal findings, and the SB technique were analyzed. The main outcome measure was the primary reattachment rate at 6 months after single surgery. Results: The mean age was 29 years (range years). The mean follow-up period was 20 months. The mean refractive error was diopters. Subretinal fluid drainage was performed in 17 eyes (37.8%). The anatomical success rate after single SB surgery at 6 months was 91.1%. The only factor that had statistically significant correlation with primary anatomical failure was development of subretinal hemorrhage during the drainage procedure (P = 0.03). Conclusion: Despite an increasing trend toward primary vitrectomy for rhegmatogenous retinal detachment, an indication for SB is in younger patients without a preexisting posterior vitreous detachment. We showed a 91.1% success rate with a primary SB and 100% with a second surgery. RETINA 0:1 6, 2016 There has been an evolution in the surgical management of rhegmatogenous retinal detachments (RRD). In the 1950s, Schepens introduced the scleral buckling procedure (SB) for the primary repair of RRD. 1 Numerous studies have reported the indications, techniques, complications, and outcomes for the SB procedure. In the 1980s with the advancement of pars plana vitrectomy, an alternative approach to retinal detachment surgery was introduced. Over the years, this has evolved from a combination of pars From the Retina Service, UPMC Eye Center, Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Supported by National Institutes of Health CORE Grant P30 EY008098, Eye and Ear Foundation of Pittsburgh, PA, Unrestricted Grant from Research to Prevent Blindness, New York, NY. Presented at the Annual Meeting of the Retina Society, Paris, France, October 10, None of the authors have any conflicting interests to disclose. Reprint requests: Andrew W. Eller, MD, UPMC Eye Center, 203 Lothrop Street, Pittsburgh, PA 15213; elleraw@upmc.edu plana vitrectomy (PPV) and SB, to PPV alone. There is an ongoing debate regarding the preferred procedure for RRD repair in terms of patient selection, convenience for surgeons, and surgical outcomes. In recent years, there has been a definite trend toward PPV as a primary procedure. Release of vitreous traction is a fundamental principle of RRD surgery. There is an obvious difference in achieving this goal between SB and PPV. A significant number of RRDs occur in younger individuals with a formed vitreous body with no detachment of the posterior cortical vitreous. 2 Releasing this traction internally with PPV may be more difficult, resulting in iatrogenic breaks, increasing the potential for proliferative vitreoretinopathy. An external approach with placement of an SB, thereby relieving the vitreous traction and supporting the retinal break(s) without the direct manipulation of a tight vitreoretinal adhesion, has several advantages, with decreased risk 1

2 2 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2016 VOLUME 0 NUMBER 0 and morbidity. A PubMed search was performed, and this is the first study to report and analyze the anatomical and functional outcomes of SB in patients with RRD without posterior vitreous detachment (PVD). Patients and Methods This study was approved by the institutional review board/ethic committee of the University of Pittsburgh. A search of our electronic database for CPT Code was performed to identify all patients undergoing surgery for a retinal detachment with an SB by a single surgeon (A.W.E.) at UPMC Eye Center between January 2005 and December From a total of 244 charts, 40 patients (45 eyes) were identified as fulfilling the criteria of presenting with an RRD without PVD and a minimum of 6 months of follow-up. Posterior vitreous detachment was defined as the presence of a Weiss ring or a visible posterior hyaloid surface on biomicroscopy. We also regarded the presence of a horseshoe tear in the preoperative records as an indication of vitreous traction secondary to a PVD. A review of the medical records was performed, and data were grouped as preoperative, intraoperative, and postoperative. Preoperative data included age, sex, refraction, duration and presenting symptom, visual acuity, status of fellow eye, and history of trauma. The retinal break(s) were classified as either round holes or dialysis. Furthermore, we recorded the number and location of breaks, extent, and distribution of the detachment by quadrants, presence of demarcation lines, and retinal macrocysts as indicators of chronicity. Intraoperative data included SB configuration (encircling vs. segmental), the type and extent of buckle component (explant), subretinal fluid drainage, intravitreal gas injection, and intraoperative complications. Postoperative details including the anatomical outcome of the SB procedure, additional surgical procedures, duration of follow-up, complications, retina status at the last follow-up visit, and the final visual acuity. Snellen acuity was converted to the logarithm of the minimal angle of resolution (logmar). The main outcome measure was primary retinal reattachment rate at 6 months after single SB surgery. Other outcome parameters were the final anatomical success rate after further operation and the final visual outcome at the last follow-up visit. All preoperative and intraoperative variables were also analyzed for their relationship to surgical success. Descriptive analysis was used to summarize the patient and operation characteristics. The findings were considered statistically significant at P, Summary demographic and preliminary descriptive statistics included the calculation of odds ratios and t-statistics. For the analysis of visual acuity and surgical outcome, to account for repeated measurements, logistic mixedeffect models with random intercepts were used. Results The study included 45 eyes of 40 patients, with a mean age of 29.2 years (range years). This represented 16.4% of patients with RRD who underwent SB surgery. All patients were phakic, and 62.5% of patients were male. The mean spherical equivalent (SE) was myopic at D (SD). Patients were followed for a mean period of 20 months (range 6 63 months). Of note, 73.4% of patients presented with symptoms including blurring of vision, loss of visual field, floaters, and photopsia. Twelve (26.6%) eyes were asymptomatic and were noted to have RRD on routine examination. Of these 12 eyes, 8 were inferior retinal detachments. All asymptomatic cases had their macula attached at diagnosis. The macula was detached in 18 eyes (40%). Eleven eyes (24.4%) were noted to have a history of significant ocular trauma. The baseline characteristics and findings on initial examination are recorded in Table 1. Table 1. Baseline Characteristics and Findings on Initial Examination Years SD or Range Age Mean Median n % Sex Male Female Refractive groups High myopia (SE $ D) Myopia Emmetropia Hyperopia 2 4 Break type Atrophic hole Dialysis Number of breaks $ Macula status On Off Trauma history

3 SCLERAL BUCKLE FOR RRD WITHOUT PVD NOORI ET AL 3 Retinal dialysis was detected in 10 eyes, and retinal detachments with atrophic holes were seen in 35 eyes on preoperative and intraoperative examination. All patients with dialysis were male. Also, a history of ocular trauma and preoperative symptoms was more common in eyes with retinal dialysis. The eyes with atrophic holes were more myopic than the eyes with retinal dialysis (Table 2). Half of the patients with dialysis were emmetropic. Seven patients had previous or newly diagnosed RRD in the fellow eye on initial examination or on follow-up visits. Two fellow eyes had previous surgery at other centers, and they were not included in the analysis. All bilateral cases were patients with high myopia with atrophic holes. Chronic RRD was defined as having symptoms for more than 3 months, or the presence of a demarcation line or retinal macrocyst. These were documented in 17 (37.8%) eyes. Demarcation lines were a feature in 22.2% of detachments but were seen in only one eye with a dialysis. A large proportion of eyes with round holes featured similar pathology in the fellow eye. Subclinical RRD in the fellow eye was present in five cases. Three patients were treated with laser barricade, and two had undergone SB. The inferotemporal quadrant was most frequently involved in detachments with both atrophic holes and the dialysis group. The standard procedure in most eyes consisted of localization of the break(s), followed by transscleral cryoretinopexy, with indirect ophthalmoscopy. A few eyes underwent further treatment with laser retinopexy of retinal holes or lattice degenerations in attached areas of the retina. In 10 cases (24.4%), the retinal break(s) (in most cases retinal dialysis) were supported by a segmental circumferential silicone tire or strip, alone. The remaining 34 (75.6%) eyes were similarly treated with a silicone explant with the addition of an encircling band. Subretinal fluid drainage was performed as judged to be necessary. The Hanscom transscleral cannula (Beaver-Visitec, Waltham, MA), a modified needle, was used for drainage of the subretinal fluid in 17 (37.8%) eyes. In this technique, after selecting the proper site, SRF drainage was achieved using indirect ophthalmoscopy for visualization. Limited subretinal hemorrhage was noted in four eyes, controlled with temporary elevation of the intraocular pressure. This maneuver successfully prevented tracking of blood toward the posterior pole. There were no instances of retinal incarceration. Internal tamponade (air or gas) was used in 16 (35.6%) eyes with superior pathology. Reattachment with a single surgery was achieved in 41 (91.1%) eyes. In the four eyes that required additional surgery, all were reattached with a subsequent vitrectomy procedure. Final anatomic success at the last follow-up visit was achieved in 100% of eyes. Using (multivariate) logistic regression analysis, primary anatomical failure had a statistically significant correlation with subretinal hemorrhage during the drainage procedure (P = 0.03). Other variables were analyzed including high myopia, the break type, the number of breaks, RRD chronicity, inferior location of RRD, and subretinal fluid drainage did not have significant correlation with failure of the primary SB surgery. One patient developed diplopia postoperatively, which later improved with removal of the buckle. The mean preoperative best-corrected visual acuity was 20/60 (0.48 in logmar), which improved to Table 2. Comparison of Different Variables in Dialysis and Atrophic Hole Groups Frequency/Mean in Eye Groups Based on Break Type (n, % or Mean) Rates (Dialysis vs. Atrophic) Variables Dialysis Atrophic Hole OR* LB HB P Sex (male) Infinite Trauma Preoperative symptom Infinite High myopia SB type (segmental) Chronic RRD Inferior RRD Detached macula Fellow eye pathology Drainage of SRF Age Refractive error VA improvement *Odds ratio with 95% confidence interval. Variables compared with t-test and presented with mean and 95% confidence interval. VA, visual acuity; LB, lower band; HB, higher band; SRF, subretinal fluid.

4 4 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2016 VOLUME 0 NUMBER 0 20/40 (0.32 in logmar). In 42.2% of the operated eyes, there was no change in vision, and this group predominantly comprised cases with the macula attached. The visual improvement was statistically significant in eyes with detached macula (P = 0.03). Discussion Since the time of Jules Gonin, retinal detachment surgery has undergone a remarkable evolution from retinopexy and sandbags to a sutureless outpatient procedure with 25-gauge vitrectomy technology. In designing this study, we posed the question, What is the role of the scleral buckle in this era of vitrectomy? Although the scleral buckle procedure can be used successfully in many types of RRD, we focused our study where we believed that the advantages of a scleral buckle clearly outweigh vitrectomy. Therefore, we elected to study that group of patients with retinal detachment without a clinically defined PVD, who tend to be younger, phakic, and with a formed vitreous. In myopia, particularly younger individuals without a PVD, RRD may develop from atrophic, round retinal holes, with or without lattice degeneration. It is presumed that an overlying pocket of liquefied vitreous may slowly seep through the hole and lead to detachment. 3 Traumatic retinal dialysis, which is more common in younger patients, is not typically associated with a PVD. These detachments are often chronic and slowly progressive in nature because of the absence of a PVD, presenting without acute symptoms, such as floaters and flashing lights. In our report, 77.8% of retinal detachments were attributed to atrophic holes, where the mean age was years, with a mean refractive error of diopters. Studies have reported that the prevalence of RRDs secondary to round retinal holes ranges from 2.8% to 21%. 4 6 Another common feature of the patients in this group was the presence of significant peripheral retinal lesions in the fellow eye. This included lattice degeneration, atrophic retinal breaks, and clinical and subclinical retinal detachments. These lesions were seen in 84.9% of fellow eyes of our patients with atrophic hole RRDs. Gonzales et al reported a prevalence of 63% in their series of phakic RRDs with atrophic hole, and Ung et al reported a prevalence of 85%, matching with our results. 3,7 Bilateral RRDs were identified in 17.5% of our patients, which is within the reported range of other studies with round hole RRD (5 33%). 4,6,7 Patients with RRD in the absence of PVD frequently exhibit retinal findings in the fellow eye that may predispose them to RRD. Therefore, careful examination, possible prophylactic treatment, and follow-up of the fellow eye are mandatory in such cases. Retinal dialysis was the causative break in 10 (22.2%) eyes. In other studies, dialysis accounted for 4% to 17% of RRDs, suggesting that it is more common when there is no preexisting PVD Seven of 10 patients with retinal dialysis presented with a history of ocular blunt trauma, and all were symptomatic. In our series, all of the retinal dialysis patients were male, with the mean age of 29.7 years, and were infratemporal in location. The slow rate of progression attributed to the absence of PVD causes a long symptom-free period, and often a late diagnosis of RRD is made, even years after trauma. The scleral buckle technique used a solid silicone, circumferential explant, with or without an encircling band. If an encircling band was applied, it was used to assist in maintaining the configuration of the buckle, and not to create a major buckling effect. Therefore, the ends of the band were connected with only gentle tension to minimize the myopic shift, inherent to the SB procedure. 15,16 The retinal pathology in a dialysis is typically limited to the area of the break alone, and in most cases an encircling band is not necessary. The decision to drain subretinal fluid was an important element in determining the success of surgery. In many cases in which there is formed vitreous, approximation of a scleral buckle to the retinal break is sufficient for reabsorption of subretinal fluid. Drainage of subretinal fluid is much more critical for inferior retinal detachments, where gas bubbles are ineffective. In 10 of 14 cases with an inferior detachment, a nondrainage procedure was successful. In two of the failed cases, there was no attempt to drain subretinal fluid. In the other two failed cases, subretinal hemorrhage was noted during the maneuver and further drainage was aborted. In both eyes, the amount of bleeding was limited to the area surrounding the drainage site. All the failed cases were subsequently repaired with single vitrectomy. The success of the second surgery was facilitated by the presence of the previously placed scleral buckle, allowing for an injection of a shorter-acting gas (sulfur hexafluoride) and faster recovery. The preferred surgery for RRD repair has evolved in recent years, with a definite trend toward pars plana vitrectomy The arguments in favor of primary PPV over SB are the direct approach to the release of vitreous traction and relative safety of internal drainage of subretinal fluid. However, inducing a PVD, especially in younger patients may be more challenging, increasing the risk of iatrogenic retinal breaks. Other potential risks include intraocular

5 SCLERAL BUCKLE FOR RRD WITHOUT PVD NOORI ET AL 5 pressure elevation, cataract formation, and the remote possibility of endophthalmitis. 19,24 28 In addition, with PPV, a gas bubble must be placed along with mandatory postoperative positioning with delayed return to normal physical activity. It may be claimed that cataract formation is not a substantial problem with the availability of advanced surgical techniques. However, pseudophakia is not a panacea, as there is the loss of accommodation, which is particularly a problem in younger patients. In cataract surgery, it is preferable to correct the vision to emmetropia with an implant lens. This may not be feasible in patients with myopia due to induced aniseikonia. In addition, postvitrectomy cataract surgery is associated with the increased risk for loose zonules and retained lens fragments. This is compounded by the additional financial burden of a second operation. Clinical trials comparing the anatomical success of PPV and SB failed to demonstrate an advantage of one over the other Some reports have shown better anatomical and visual outcomes with SB surgery in phakic patients. 28,29 In our series, the primary success rate of retinal reattachment was 91.1% with a 100% final reattachment rate. This study is limited by its retrospective nature and the experience of a single surgeon. Another limitation of the study was the diagnosis of PVD based on clinical examination alone, and B-scan ultrasound or optical coherence tomography was not used to evaluate the status of the vitreous. As primary vitrectomy for repair of RRD continues to gain popularity, an important role remains for the SB procedure. This is particularly evident in younger patients without a preexisting PVD in which vitrectomy may present a much greater challenge, and the SB is the simpler procedure. Similarly, patients with a partial PVD and retinal detachment may also benefit from the inherent advantages of repair with a scleral buckle. This is particularly true in younger phakic patients. The advantages of SB are numerous, including preservation of lens and accommodation, no requirements for special positioning, more rapid return to activities, no travel restriction, and reduced risk for iatrogenic retinal breaks and endophthalmitis, as without drainage, it is solely an extraocular procedure. Key words: posterior vitreous detachment, rhegmatogenous retinal detachment, scleral buckle. References 1. Kishore K, Peyman GA. Vitreoretinal surgical techniques. In: Peyman GA, Meffert S, Conway MD, Chou F, eds. Techniques of Scleral Buckling for Retinal Detachment Repair. London, United Kingdom: Martin Dunitz; 2001: Blindbaek S, Grauslund J. Prophylactic treatment of retinal breaks a systematic review. Acta Ophthalmol 2015;93: Ung T, Comer MB, Ang AJS, et al. 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6 6 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2016 VOLUME 0 NUMBER Hakin KN, Lavin MJ, Leaver PK. Primary vitrectomy for rhegmatogenous retinal detachment. Graefes Arch Clin Exp Ophthalmol 1993;231: Heimann H, Bornfeld N, Friedrichs W, et al. Primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment. Graefes Arch Clin Exp Ophthalmol 1996;234: Miki D, Hida T, Hotta K, et al. Comparison of scleral buckling and vitrectomy for superior retinal detachment resulting from flap tears in superior quadrants. Jpn J Ophthalmol 2001;45: Sun Q, Sun T, Xu Y, et al. Primary vitrectomy versus scleral buckling for the treatment of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled clinical trials. Curr Eye Res 2012;37: Adelman RA, Parnes AJ, Sipperley JO, Ducournau D; European Vitreoretinal Society (EVRS) Retinal Detachment Study Group D. Strategy for the management of complex retinal detachments; the European vitreo-retinal society retinal detachment study report 2. Ophthalmology 2013;120: Thelen U, Amler S, Osada N, Gerding H. Outcome of surgery after macula-off retinal detachment results from MUSTARD, one of the largest databases on buckling surgery in Europe Results from a large German case series. Acta Ophthalmol 2012;90: