CLINICAL SCIENCES. for managing primary rhegmatogenous

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1 CLINICAL SCIENCES Pars Plana Vitrectomy Alone With Diffuse Illumination and Vitreous Dissection to Manage Primary Retinal Detachment With Unseen Breaks Vicente Martínez-Castillo, MD; Anna Boixadera, MD; José García-Arumí, MD Objective: To report on pars plana vitrectomy with diffuse illumination, wide-angle viewing, and meticulous vitreous dissection for identifying and managing retinal breaks when no breaks were detected before surgery for primary rhegmatogenous retinal detachment. Methods: Prospective clinical study of 6 of 800 consecutive eyes (7.6%) (6 of 782 patients) seen at a university hospital during the 48-month study for primary rhegmatogenous retinal detachment in whom no break could be identified despite thorough examinations. All of the patients underwent pars plana vitrectomy alone with meticulous peripheral vitreous dissection assisted by diffuse illumination, a wide-angle viewing system, perfluorocarbon liquid, triamcinolone acetonide suspension, and balanced salt solution to identify and manage primary retinal breaks. Results: Retinal breaks were found intraoperatively in 60 eyes (98%). In 5 of 6 eyes (84%), balanced salt solution was left in the vitreous cavity. Best-corrected visual acuity was 20/40 or better in 25 of 6 study eyes (4%). Primary retinal reattachment was attained in 60 study eyes (98%). Final reattachment was achieved in all 6 eyes (00%). Conclusions: Pars plana vitrectomy alone with diffuse illumination and extensive vitreous dissection led to identification and management of retinal breaks undetectable before surgery, achieving a high primary reattachment rate. Arch Ophthalmol. 2009;27(0): Author Affiliations: Vall d Hebrón Hospital, Universidad Autónoma de Barcelona (Drs Martínez-Castillo, Boixadera, and García-Arumí), and Instituto de Cirugía Ocular Avanzada de Barcelona (Drs Martínez-Castillo and Boixadera), Barcelona, Spain. THE PRINCIPLES OF SURGERY for managing primary rhegmatogenous retinal detachment (RRD) are to precisely identify and correctly treat all causative retinal breaks. Traditionally, the preoperative examination to find the retinal break has been considered as important as the surgical technique for its management. 2 However, even a diligent preoperative examination does not disclose the primary break in 2.2% to 22.5% of cases of primary RRD. 3,4 Video available online at Various strategies have been used to identify and manage primary retinal breaks intraoperatively when they have not been found before surgery, including circumferential buckling, broad retinopexy, scleral buckling, and pars plana vitrectomy (PPV). 5-3 When retinal breaks can be identified intraoperatively, primary reattachment rates are significantly higher than when retinal breaks cannot be identified before or during surgery. 5-2 During recent years, advances in the PPV technique have occurred that allow the surgeon to conduct a detailed intraoperative examination of the peripheral retina and, thereby, identify small retinal breaks located at the vitreous base. The aim of the present prospective study is to determine the success of PPV alone with a diffuse illumination system, dynamic scleral depression (DSD), and meticulous vitreous base dissection in cases in which primary retinal breaks had not been detected during extensive preoperative examinations. METHODS Candidates for this study were 782 patients (800 consecutive eyes) who were scheduled for surgical repair of primary RRD at Vall d Hebrón Hospital, Barcelona, Spain, by 2 of us (V.M.-C. and A.B.) during a 48-month period. The study protocol was approved by the institutional review board of Vall d Hebrón Hospital. Patients with redetachment, recur- 297

2 In some eyes, a break was identified by noting a primary (spontaneous) Schlieren effect (efigure A; 4 In other eyes, the Schlieren effect occurred secondary to peripheral vitrectomy with 360 DSD or another maneuver (efigure B). Additional procedures were performed to identify the first break or additional retinal breaks as follows: injection of perfluorocarbon liquid (PFO) (DK Line; Bausch & Lomb Inc, Waterford, Ireland) over the posterior pole and 360 DSD, then injection of 0.5 to.0 ml of an aqueous suspension of triamcinolone acetate (TA) (Trigon Depot, 40 mg/ml; Bristol- Myers Squibb SL, New York, New York) prepared as described elsewhere 5 and dissection of the vitreous base with 360 DSD. PATIENT GROUPS Figure. Surgeon s view of pars plana vitrectomy for the identification and management of primary rhegmatogenous retinal detachment. Peripheral vitreous dissection with dynamic scleral depression led to identification of the primary break (arrow). rent retinal detachment, giant tears, retinal detachment due to a macular hole, corneal decompensation, dense cataract, or vitreous hemorrhage were excluded from the study. Preoperative assessments included evaluation of the anterior segment, measurement of pupil size, fundus examination, and evaluation of the peripheral retina by indirect ophthalmoscopy with scleral depression and slitlamp biomicroscopy using a fundus contact lens, all performed by one of us (V.M.-C.). In 6 candidate eyes (6 patients), no retinal break could be detected, and the patient/eye was enrolled in the study. Each patient underwent PPV without an encircling buckle and using a series of maneuvers to identify the retinal break(s) intraoperatively. In phakic eyes, at the beginning of the surgical procedure, the lens was removed by means of phacoemulsification, and a posterior chamber intraocular lens was inserted. All of the patients received acrylic lenses via a clear corneal incision. PPV PROCEDURE Under retrobulbar anesthesia, 3- or 4-port PPV was performed using a wide-angle viewing system and lighted infusion, a 25-gauge sutureless xenon chandelier light (Synergetics USA Inc, O Fallon, Missouri), or both at the surgeon s discretion. When needed, iris hooks were used intraoperatively to increase mydriasis. A fiberoptic light was used as needed to identify and examine retinal breaks. Eyes were classified according to when in the operative procedures the first retinal break was identified (see the Patient Groups subsection). A retinal break was defined as primary when it was judged from the contour of the detachment that this break alone could account for the detachment. A break was defined as secondary when the contour of the detachment could not be accounted for by this break alone. 2 PROCEDURES USED TO IDENTIFY RETINAL BREAKS INTRAOPERATIVELY The first operative procedures used to identify retinal breaks intraoperatively in all eyes were DSD and peripheral vitrectomy. The DSD was started at the most probable location of the retinal break and then continued along the entire retinal periphery. The surgeon performed all DSDs using a scleral depressor or a muscle hook. Simultaneous vitrectomy and depression were accomplished using diffuse illumination. Eyes were assigned to group when the first retinal break was identified by the initial DSD and peripheral vitrectomy with 360 DSD. Eyes were assigned to group 2 when the first retinal break was not seen until the next step, injection of PFO with 360 DSD. If injection of PFO did not result in any indirect signs, the whole retinal periphery was examined by using DSD to look for direct signs of the location of the retinal break. Retinal breaks could sometimes be identified by a flap or operculum on the slope of the DSD (Figure). Eyes were assigned to group 3 when the first retinal break was not identified until injection of TA and peripheral vitreous dissection at the vitreous base with 360 DSD. MANAGEMENT OF RETINAL BREAKS Retinal breaks were managed intraoperatively using different maneuvers to completely drain subretinal fluid from the borders of every retinal break. 6 When no retinal break could be identified with the vitreous cavity filled with PFO or air, then circumferential retinopexy was performed using a diode laser, and the vitreous cavity was filled with silicone oil. After retinopexy of breaks identified while the vitreous cavity was filled with air, the air was exchanged for balanced salt solution and the whole periphery was carefully examined for secondary breaks under scleral depression. 6 Follow-up postsurgical examinations were performed at, 3, and 7 days; 2 weeks; and, 3, 6, and 2 months. STATISTICAL ANALYSIS Statistical analysis were performed using a software program (SPSS version 5.0; SPSS Inc, Chicago, Illinois). The 2 and Fisher exact tests were used to compare categorical data, and the t test was used to compare continuous data. P.05 was considered statistically significant. RESULTS Table details findings for each of the 6 patients (6 eyes) in this study. The mean (SD) patient age was 65 (3.7) years (age range, 9-86 years). Thirty-eight patients (62%) had myopia of less than 6 diopters (D), and 23 (38%) had myopia of 6Dormore. In 3 eyes, the duration of symptoms or detachment was unknown. For the remaining 58 eyes, the mean (SD) duration of retinal detachment was 29.3 (4.8) days (range, day to 6 months); in 36 of these 58 eyes (62%), the duration was less than 2 weeks. At the time of PPV, eyes were phakic (8%), 4 were pseudophakic (67%), and 9 were aphakic (5%). The mean (SD) 298

3 Table. Clinical Characteristics of 6 Eyes With Rhegmatogenous Retinal Detachment Patient No./ Sex/Age, y Myopia, Diopters Duration of Detachment Crystalline Lens Time From Cataract Surgery to PPV, mo Type of Surgery IOL PC Preoperative BCVA Final BCVA Follow-up, mo Events During Follow-up /M/ d Aphakic HM HM 46 None 2/F/ d Pseudophakic HM 20/ None 3/M/ Unknown Pseudophakic CF 20/00 45 None 4/M/ d Aphakic CF 20/30 6 None 5/M/ wk Pseudophakic /400 20/50 35 None 6/F/ wk Aphakic CF 20/ OH 7/M/ d Aphakic /400 20/ None 8/M/ d Pseudophakic HM 20/200 2 None 9/M/ d Pseudophakic HM 20/40 38 None 0/M/ wk Pseudophakic /00 20/20 38 None /F/ d Pseudophakic /25 20/25 2 CRVO 2/M/ mo Pseudophakic /400 20/ None 3/M/ d Pseudophakic /400 20/25 36 MNVM 4/M/ d Pseudophakic HM 20/00 35 None 5/M/ d Pseudophakic /200 20/50 35 None 6/M/ wk Pseudophakic /200 20/25 34 None 7/F/ wk Aphakic /400 20/ None 8/M/ d Pseudophakic /50 20/25 33 None 9/M/8 0 Unknown Phakic /400 20/60 33 None 20/M/ d Pseudophakic /200 20/40 33 None 2/M/64 4 d Pseudophakic /20 20/20 32 None 22/M/ mo Phakic /400 20/00 32 None 23/M/ d Pseudophakic /400 20/30 3 None 24/F/ d Pseudophakic HM 20/50 3 None 25/M/ wk Pseudophakic 25 20/40 20/40 30 None 26/F/ wk Phakic HM 20/50 30 None 27/F/ d Pseudophakic /25 20/20 30 None 28/M/ d Pseudophakic HM 20/40 29 None 29/F/72 0 Unknown Phakic HM 20/40 27 None 30/F/ mo Phakic HM 20/00 27 None 3/M/ wk Pseudophakic /400 20/50 26 None 32/F/4 0 6 wk Pseudophakic /200 20/00 25 None 33/F/ d Aphakic HM 20/ OH 34/M/ d Pseudophakic /400 20/30 24 None 35/M/ d Pseudophakic HM 20/40 24 None 36/M/ d Phakic /400 20/60 9 None 37/M/ wk Pseudophakic CF 20/00 23 None 38/M/ d Phakic CF 20/200 8 None 39/M/ d Aphakic /400 20/400 8 Corneal ulcer 40/M/ mo Pseudophakic CF 20/200 8 None 4/F/ wk Pseudophakic 2 20/400 20/400 7 None 42/M/ d Aphakic CF 20/400 8 None 43/M/ d Pseudophakic HM 20/00 7 None 44/M/ d Pseudophakic /20 20/20 7 None 45/F/7 0 5 mo Pseudophakic CF 20/00 7 None 46/F/ wk Pseudophakic HM 20/00 6 None 47/M/6 0 2 d Pseudophakic CF 20/30 6 None 48/M/ d Phakic /20 20/20 4 None 49/M/ d Pseudophakic HM 20/400 4 None 50/F/80 6 wk Pseudophakic /00 20/60 3 None 5/M/ mo Phakic /00 20/50 2 None 52/M/ wk Pseudophakic CF 20/40 2 None 53/F/ d Phakic /400 20/200 None 54/M/ d Pseudophakic /60 20/30 2 None 55/M/ mo Aphakic CF 20/400 None 56/M/ wk Pseudophakic /200 20/50 None 57/M/ d Phakic /25 20/25 None 58/M/ d Pseudophakic /200 20/50 None 59/M/ d Pseudophakic /25 20/25 0 Conjunctival cyst 60/M/ d Pseudophakic /400 20/40 0 None 6/F/ d Pseudophakic /200 20/25 46 None Abbreviations: BCVA, best-corrected visual acuity; CF, counting fingers; CRVO, central retinal vein occlusion; HM, hand movements; IOL, intraocular lens; MNVM, myopic neovascular membrane; OH, ocular hypertension; PC, posterior capsule; PPV, pars plana vitrectomy; 0, phakic. 299

4 Table 2. Characteristics of Rhegmatogenous Retinal Vitrectomy Patient No. Macula Qts, No. Breaks, No. Type Off 4 4 H, H, H, H Disc Diameter 2, 4, 4, 4 Clock Hour Position, :30, 2, 3 Location PVR Grade Group No. a Identification of Primary Break Schlieren Effect Total PVD Sclerotomies, No. Tamponade Agent A, A, A, A 0 Direct No Presence 3 BSS 2 Off 3 2 H,H 2, 2 3, 0 P, A B Direct Yes (P) Lack 3 C3F8 3 Off 4 2 H,H 4, 2, A, A 0 Direct Yes (P) Presence 3 BSS 4 Off 3 AH 4 2 A 0 2 Indirect Yes (S) Presence 4 BSS 5 Off 4 AH 2 A 0 Indirect Yes (S) Presence 3 BSS 6 Off 3 2 H, AH 4, 4 2:30, 5 A, A 0 Direct Yes (S) Presence 3 BSS 7 Off 4 H 2 2 A 0 Indirect Yes (S) Presence 3 BSS 8 Off 4 H 4 2:30 A 0 2 Indirect Yes (S) Presence 3 BSS 9 Off 3 4 H, H, H, H 4, 4, 4, 4 6:30, 7:30, 9:30, :30 A, A, A, A 0 Direct No Presence 3 BSS 0 On 2 H 2 :30 A 0 Direct No Presence 3 BSS On 2 H 4 :.30 A 0 3 Direct No Presence 3 BSS 2 Off 3 AH 4 2:5 A C 3 Indirect Yes (S) Presence 4 BSS 3 Off 2 2 H, H 4, 4, :30 A, A 0 Direct No Presence 3 BSS 4 Off 4 AH 4 A 0 Direct No Presence 3 BSS 5 Off 2 H 4 5:30 A 0 Direct No Presence 3 BSS 6 Off 4 AH 4 3:30 A 0 3 Indirect Yes (S) Lack 4 BSS 7 Off 4 H 2 2:30 A B 2 Direct Yes (S) Presence 3 BSS 8 Off 3 2 H, H 2, 4 6:30, :30 A, A 0 Direct No Presence 3 BSS 9 Off 4 H 2 :30 A 0 Direct Yes (P) Presence 3 BSS 20 Off 3 4 H, H, H, 4, 4,, 2, 3:30, A, A, A, A 0 Direct Yes (S) Presence 4 BSS AH 4, 2 4:30 2 On 2 H 4 2 A 0 2 Direct Yes (P) Presence 3 BSS 22 Off 4 H 4 2 A B 3 Indirect Yes (S) Presence 4 BSS 23 Off 4 2 AH, H 4, 2, 0 A, A 0 3 Direct No Presence 4 BSS 24 Off 4 H 2 :30 A C Direct Yes (S) Presence 4 C3F8 25 On 4 H 4 2:30 A 0 3 Direct Yes (S) Presence 3 BSS 26 Off 4 H 4 E 0 Direct No Presence 3 BSS 27 On 2 H 4 2:30 A 0 Direct No Presence 3 BSS 28 Off 4 AH 4 :45 A 0 3 Indirect Yes (S) Presence 4 BSS 29 Off 4 H 4 0:30 A 0 Direct No Presence 3 BSS 30 Off 4 AH 4 2 A 0 3 Indirect Yes (S) Presence 4 BSS 3 Off 4 AH 4 :30 A C 3 Indirect Yes (S) Presence 4 BSS 32 Off 3 H 4 7 A 0 3 Direct No Presence 4 BSS 33 Off 2 H 4 A 0 3 Direct No Presence 4 BSS 34 Off 2 H 2 A 0 Direct No Lack 3 BSS 35 Off 4 H 4 :30 A 0 3 Direct No Presence 4 BSS 36 Off 4 H 4 A 0 Direct Yes (P) Presence 4 BSS 37 Off 3 2 H, H 4, 4 4, 7 A, A 0 2 Direct No Presence 4 BSS 38 Off 3 H 4 7 P 0 Direct No Lack 3 BSS 39 Off 4 2 H, H 4, 4, A, A 0 2 Indirect Yes (S) Presence 3 Air 40 Off 4 AH 4 2:30 A B Direct Yes (S) Presence 3 BSS 4 Off 3 H 2 7 A 0 Direct No Presence 4 BSS 42 Off 3 NF NF 0 NF No Presence 4 SO 43 Off 4 H 2 2:30 A B Direct Yes (S) Presence 3 BSS 44 Off 3 2 AH, H 2, 2, 3 A, A 0 Direct No Presence 4 Air 45 On 3 H 4 :30 A 0 Indirect Yes (S) Presence 3 BSS 46 Off 4 2 H, H 2, 4 5, A, A 0 2 Direct Yes (S) Presence 4 BSS 47 Off 4 3 H, H, H 4, 4, 9,, 5 A, A, A 0 Direct No Presence 4 Air 4 48 Off 2 AH 4 5 A 0 Direct No Lack 3 Air 49 On 3 2 H, H 4, 4 2:30, 5:30 A, A B 2 Direct No Presence 3 C3F8 50 Off 4 H 4 A 0 Direct Yes (P) Presence 3 C3F8 5 Off 3 H 4 0:30 A 0 Direct Yes (S) Presence 4 BSS 52 Off 3 H 4 2:30 A 0 2 Direct Yes (S) Presence 3 BSS 53 Off 3 AH 4 A B Indirect Yes (S) Presence 3 BSS 54 Off 3 2 H, H 4, 4 2, 5:30 A,A 0 Direct No Presence 3 BSS 55 Off 3 H 4 2:30 A 0 Indirect Yes (S) Presence 4 C3F8 56 Off 2 H 4 8 A 0 3 Direct Yes (S) Presence 4 BSS 57 Off 2 H 4 4 A 0 2 Direct No Presence 3 BSS 58 On 2 2 H, H 4, 4 6:30, 8 A, A 0 2 Direct No Presence 3 BSS 59 Off 2 H 4 8:30 A 0 3 Direct Yes (S) Presence 4 BSS 60 Off 4 H 4 A 0 Direct Yes (S) Presence 3 BSS 6 Off 3 2 H, H 4, 4 0:30, A, A 0 Direct Yes (P) Presence 4 BSS Abbreviations: A, anterior; AH, atrophic hole; BSS, balanced salt solution; E, equatorial; H, horsehoe tear; NF, not found; P, posterior; (P), primary; PVD, posterior vitreous detachment; PVR, proliferative vitreoretinopathy; Qts, quadrants; (S), secondary; SO, silicone oil. a Groups are defined by the number of intraoperative maneuvers needed to identify the first break. See the Patient Groups subsection for a description of each group. 300

5 Table 3. Characteristics of Single Retinal Breaks in 42 Eyes by Group a Table 4. Characteristics of 85 Retinal Breaks Identified Intraoperatively in 60 Eyes by Group a Eyes, No. (%) Characteristic Group (n=23) Group 2 (n=6) Group 3 (n=3) P Value b Identification mode.34 Direct signs 8 (62) 4 (4) 7 (24) Indirect signs 5 (38) 2 (5) 6 (46) Shape.36 Horseshoe tear 8 (60) 5 (7) 7 (23) Atrophic hole 5 (45) (9) 5 (45) Position.99 Superior 20 (56) 5 (4) (3) Inferior 3 (50) (7) 2 (33) Size relative to.04 disc diameter 4 6 (33) 2 () 0 (56) 4 9 (60) 3 (20) 3 (20) 2 7 (88) (3) 0 2 (00) 0 0 a Groups are defined by the number of intraoperative maneuvers needed to identify the first break. See the Patient Groups subsection for a description of each group. b Fisher exact test. time from cataract surgery to PPV was 76.8 (86.7) months (range, -359 months). For all 6 study eyes, the mean (SD) pupil size was 7 () mm (range, mm). The retinal detachment involved 2 quadrants in 2 eyes (20%), 3 quadrants in 2 (34%), and 4 quadrants in 27 (44%). Seven of the 6 patients (%) were first seen with proliferative vitreoretinopathy (PVR) grade B and 3 (5%) with PVR grade C. The macula was attached in 8 eyes (3%) and detached in 53 (87%). Mean (SD) follow-up was 24.8 (.) months (range, 6-46 months). CHARACTERISTICS OF RETINAL BREAKS IDENTIFIED INTRAOPERATIVELY Table 2 details the characteristics of all 85 retinal breaks identified intraoperatively in the 6 patients/eyes in this study. Of the 60 eyes (98%) in which breaks were identified intraoperatively, 42 (70%) had a single break. Seventy breaks (82%) were horseshoe tears and 5 (8%) were atrophic holes. Of these 85 breaks, 82 (96%) were anterior to the equator, (%) was at the equator, and 2 (2%) were posterior to the equator. Sixty-four (75%) of the 85 breaks were superior, and the other 2 (25%) were inferior. Of the 85 breaks, 29 (34%) were less than 4 disc diameter, 37 (44%) were 4 disc diameter, 8 (2%) were 2 disc diameter, and (%) was greater than 2 disc diameter. Table 3 summarizes the characteristics of the 42 single retinal breaks identified intraoperatively in 42 eyes with only break according to group (defined by the number of intraoperative maneuvers needed to identify the first break). For the 42 eyes with a single break, group number (the number of procedures needed) was related to the break s size (P=.04) (Table 3). Table 4 summarizes the characteristics of the 85 retinal breaks identified intraoperatively in the 60 eyes in Eye or Retinal Break Characteristic High myopia ( 6 diopters), No. (%) Pupil size, mean (SD), mm Duration of detachment, mean, d Group (n=35) Group 2 (n=) Group 3 (n=4) P Value b 5 (65) 5 (22) 3 (3) (0.88) 7 (.24) 7.03 (.29) Lens status, No. (%).59 Phakic 8 (73) (9) 2 (8) Pseudophakic 23 (56) 7 (7) (27) Aphakic 4 (50) 3 (38) (3) Intraocular lens,.66 No. (%) 0 4 (50) 3 (38) (3) 2 (40) 2 (40) (20) 2 3 (75) 0 (25) 3 8 (56) 5 (6) 9 (28) Posterior capsule.36 status, No. (%) 0 5 (7) 2 (29) 0 2 (63) 3 (6) 4 (2) 2 0 (43) 5 (22) 8 (35) Macula status, No..873 On Off Detachment extension,.7 No. (%) 2 Quadrants 6 (50) 3 (25) 3 (25) 3 Quadrants 4 (67) 4 (9) 3 (4) 4 Quadrants 5 (55) 4 (5) 8 (30) Retinal breaks, No..07 Single Multiple 2 5 Duration of operation, mean (SD), min Total group 67.4 (7) 74 (4) 9.4 (5.4).00 Eyes with single breaks 66.9 (9.5) 68.3 (0.8) 90.7 (5.9).00 Eyes with multiple breaks 67.5 (.7) 8 (5.5) a Groups are defined by the number of intraoperative maneuvers needed to identify the first break. See the Patient Groups subsection for a description of each group. b Fisher exact test. this study. Of the 35 eyes in group, 23 (66%) had a single break and 2 (34%) had multiple breaks. Of the 2 eyes in group with multiple breaks, in 7 (58%) the first retinal break identified was the primary break and in 5 (42%) it was a secondary break. Of the 60 first retinal breaks identified intraoperatively, 46 (77%) were identified directly and 4 (23%) were discovered through indirect signs. The schlieren effect was observed in 34 eyes (57%); it was primary in 7 eyes (2%) and secondary in 27 (79%). Of 8 eyes with multiple breaks, in 9 (50%) the first break identified was the primary break and in 9 (50%) the first break identified was a secondary break. In 6 of 8 eyes with multiple breaks (33%), the secondary breaks were located within 2 clock hour positions of the primary retinal break, and in the other 2 (67%), they were not. 30

6 When the vitreous cavity was filled with balanced salt solution, in 3 (5%) of 60 eyes a secondary break was identified. At the end of surgery in the 6 eyes, balanced salt solution was left in the vitreous cavity in 5 (84%), air was left in 4, 2% of perfluoropropane gas and air mixture was left in 5, and silicone oil was left in. Four of 6 eyes (7%) had vitreous incarceration at the sclerotomy site (patients 4, 25, 44, and 5), and in of the 6 eyes (2%), a retinal break developed at the sclerotomy site. VISUAL ACUITY For all 6 study eyes, the mean preoperative best-corrected visual acuity (BCVA) was 20/25 (range, hand movements to 20/20), and the mean final BCVA was 20/50 (range, hand movements to 20/20) (Table ). No significant differences were noted among the 3 groups in preoperative BCVA (P=.68) and final BCVA (P=.6). Visual acuity was 20/40 or better in 25 of 6 study eyes (4%). The mean final BCVA was significantly better relative to the mean preoperative BCVA (P.007). There were 8 eyes with macula-attached RRD (Table 4), with a mean preoperative BCVA of 20/26 (range, 20/ 00 to 20/20) and a mean final BCVA of 20/22 (range, 20/40 to 20/20). For the 53 eyes with macula-detached RRD, the mean preoperative BCVA was 20/300 (range, hand movements to 20/25), and the mean final BCVA was 20/60 (range, hand movements to 20/25). RETINAL REATTACHMENT Primary retinal reattachment, defined as complete reabsorption of subretinal fluid at 3 months, was attained in 60 of 6 study eyes (98%; 95% confidence interval, 9.2%- 99.9%). The single reattachment failure was the only case in which the retinal break could not be identified intraoperatively. This patient underwent PPV combined with scleral buckling and photocoagulation of the posterior border of the buckle and silicone oil tamponade. This treatment was successful. Thus, we achieved final reattachment in all 6 eyes by the 2-month follow-up visit. COMMENT The surgical management of primary RRD when no retinal break can be seen has been controversial, particularly when no break can be found despite the presence of clear medium in the vitreous during the surgical technique. 5,2 Wong et al 5 reported in 987 on the results of PPV combined with scleral buckling; the causative breaks were identified in 8 of 47 cases (38%), with a reattachment rate of 60%. The authors stated that the undiscovered holes were probably located in the preequatorial retina, where the view was poor at vitrectomy. Salicone et al, in a retrospective comparative study, did not find the causative breaks in 8 cases treated with PPV combined with scleral buckling. Table 5 summarizes findings in these and other major studies. 5- In the present prospective clinical study, we identified the causative breaks in 60 of 6 eyes, and primary reattachment occurred in all 60 of these eyes (98%). FACTORS FOR SUCCESS WITH THIS PROTOCOL Several factors (described in the following subsections) contribute to the success of this protocol for identifying and managing eyes with primary RRD in which retinal breaks could not be detected. Vitreous Dissection at the Sclerotomy Sites During vitrectomy, peripheral vitreous incarceration at the sclerotomy site is a risk factor for a retinal break. Despite advances in instrumentation, the rate of iatrogenic retinal breaks during PPV has been reported to be.6%. 7 Using the protocol described herein for the recognition and treatment of vitreous incarceration and meticulous examination of the retinal periphery at the sclerotomy site, we achieved a low incidence of sclerotomy site tears (.6%). Extension of Subretinal Fluid and DSD The RRDs form in a predictable manner around the hole of origin, and the shape of the detachment indicates the position of the primary break 96% of the time. 2 The extension of subretinal fluid is governed by the position of the break, the effect of gravity, and anatomical limits. In the present study, the use of independent diffused illumination systems combined with DSD allowed us to accurately establish the limits of detachment and to identify at least retinal break in 35 patients. In some cases, the first break identified was secondary, and in many of these we identified the primary break by following the extension of subretinal fluid to the primary break. Perfluorocarbon Liquid The PFO permits stabilization of the posterior retina and elevation of the peripheral detached vitreous and promotes the Schlieren effect. 7 However, despite a meticulous search with DSD after injection of PFO, we identified a retinal break in only of 25 eyes that had a retinal break not identified or intraoperatively by means of peripheral vitrectomy and DSD before injection of PFO. We attribute the relatively low proportion of retinal breaks identified using PFO to the small size of the retinal breaks and the small amount of subretinal fluid streaming out through the breaks. Meticulous Peripheral Vitreous Dissection After PFO and TA Injection The goal of dissection of the peripheral vitreous after injection of PFO and TA, with DSD, is to create drainage of subretinal fluid through the break. Subretinal fluid drainage promotes identification of previously unseen breaks by means of the Schlieren effect. The DSD may also lead to direct identification of retinal breaks on the slope of the depression or indirect identification through the Schlieren effect (video available at Subretinal fluid drainage from the borders of the retinal break permits the surgeon to seal retinal breaks intraoperatively and, thus, to avoid the use of a postoperative tamponade agent

7 Table 5. Characteristics of Studies of Pars Plana Vitrectomy (PPV) With or Without Scleral Buckling (SB) for Rhegmatogenous Retinal Detachment (RRD) Source Wong et al, Study Period Design Surgical Technique Prospective, consecutive case series PPV SB (2 groups: good [n=25] and poor [n=22] preoperative view) Desai and 993- Prospective Strassman, case series 997 Brazitikos et al, Wu et al, Kocaoglan et al, Tewari et al, Salicone et al, Prospective 997 PPV SB (retinotomy extensive photocoagulation C3F8) PPV and PPV SB (n=5) Population, No. a Inclusion Criteria 47 No break identified 0 Only pseudophakic RRDs with unseen breaks 4 (87) No break identified 994- Prospective, SB 25 (02) No break seen 998 consecutive 997- Retrospective; SB 45 (258) Unseen breaks 2000 compares cases with unseen breaks with cases with identified breaks and perioperatively Before 2002 Prospective, consecutive SB and SB PPV 989- Retrospective, SB and SB 2003 consecutive PPV 44 No break seen despite clear media 44 (692) No definite break seen or intraoperatively despite clear media with macular involvement Exclusion Criteria NR NR PVR grade B PVR grade B, giant tear, trauma Secondary RRD, PVR grade C2, and insufficient follow-up PVR grade C, media opacities, and lost to follow-up Macula-on RRD, media opacities, probable break or definite break found intraoperatively, cases treated with PPV alone Lens 5 aphakic and 9 underwent lensectomy Pseudophakic or aphakic Only pseudophakic Only pseudophakic Initial Reattachment, % NR 22 Aphakic and 62.2 and pseudophakic 78.9 and 23 phakic 9 Phakic and 3 70 and pseudophakic 80 and aphakic 2 Phakic 6.5 and and pseudophakic Abbreviations: NA, not available; NR, not reported; PVR, proliferative vitreoretinopathy. a The number in parentheses is the number provided by the authors of the total number of cases in the population studied. Final Reattachment, % 60 and 59 Follow-up, Mean (Range), mo NR (6-36) Comments In 29 of 47 cases, holes were not found (6-32) Includes primary and secondary cases; in 2 cases, a retinal break was identified (3-3) Retinal breaks were identified in 3 of 4 cases (6-56) PPV with retinotomy only for redetachment 87.2 and (6-42) After vitrectomy for redetachment in cases with unseen breaks, reattachment rate was 55% (6/) NA 4 (3-6) Authors detected unseen breaks during PPV in 55% of cases 83.3 and (-76) In most cases, retinotomy for internal drainage of subretinal fluid and 360 diode laser photocoagulation were performed COMPARISON WITH PREVIOUS STUDIES As in most studies of how to identify and manage primary retinal breaks not seen before surgery, we limited the study population to eyes with clear media. However, not all previous studies describe the exclusion criteria 5,6 or describe other or additional exclusion criteria, such as a preoperative PVR grade of B or C 7-0 or exclusion of macula-attached RRD treated with PPV alone. The present study population had a higher proportion of pseudophakic and aphakic eyes compared with populations in previous studies 5-2 of unseen retinal breaks. Small breaks located at the posterior border of the vitreous base are more prevalent in pseudophakic eyes compared with phakic eyes with retinal detachment. 8 In these cases, lens status, pupil size, position of the intraocular lens, and status of the posterior capsule make preoperative identification of breaks more difficult, but they did not hinder intraoperative identification of retinal breaks using the present protocol, as shown by the lack of a significant difference in results for lens status, intraocular lens, and posterior capsule status in Table 4. CLINICAL SIGNIFICANCE OF FINDINGS This study has several findings of importance to surgeons who treat primary RRD in which no retinal break 303

8 can be seen. Most important, the protocol we used to identify retinal breaks intraoperatively that had not been seen was effective in finding causative breaks in 60 of 6 eyes and in achieving a final reattachment rate of better than 98%. It is also important that, after we found a single break in 42 of 60 eyes (70%), continuing the search led to the discovery of multiple breaks (2-4) in the remaining 30%. We performed meticulous peripheral vitrectomy to identify retinal breaks when no break could be seen before surgery for retinal detachment, and we found a significant relationship between the need for peripheral vitrectomy with TA (more procedures) to identify a break and smaller size of the break as it appeared to the surgeon when it was finally detected (Table 3). We found that, when the primary retinal break was undetected at the most probable position according to the distribution of subretinal fluid, it could still be located by means of injection of PFO and DSD (group 2) or by the use of TA suspension to identify the vitreous and peripheral vitrectomy with DSD (group 3) in 98% of eyes (video available at We found that the first retinal break identified was the primary break in 44% of eyes. Regarding the location of secondary breaks, in 6 eyes, the secondary break was located within 2 clock hour positions of the primary break, but, in 2 eyes, the secondary break was located farther from the primary break. In summary, this prospective study showed that retinal breaks that cause primary RRD that were not seen can be identified intraoperatively in approximately 98% of patients, achieving a high primary reattachment rate. Submitted for Publication: December 3, 2008; final revision received April 28, 2009; accepted April 29, Correspondence: Vicente Martínez-Castillo, MD, Calle Londres n 54 4 B, Barcelona, Spain (3756vmc@comb.es). Financial Disclosure: None reported. Additional Information: The efigure and videos are available at REFERENCES. Gonin J. Treatment of detached retina by sealing the retinal tears. Arch Ophthalmol. 930;4: Lincoff H, Gieser R. Finding the retinal hole. Arch Ophthalmol. 97;85(5): Ashrafzadeh MT, Schepens CL, Elzeneiny II, Moura R, Morse P, Kraushar MF. Aphakic and phakic retinal detachment, I: preoperative findings. Arch Ophthalmol. 973;89(6): Cousins S, Boniuk I, Okun E, et al. Pseudophakic retinal detachments in the presence of various IOL types. Ophthalmology. 986;93(9): Wong D, Billington BM, Chignell AH. Pars plana vitrectomy for retinal detachment with unseen retinal holes. Graefes Arch Clin Exp Ophthalmol. 987;225 (4): Desai UR, Strassman IB. 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