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Scleral Buckling versus Primary Vitrectomy
Ophthalmology Volume 113, Number 7, July 2006 2. Wilkinson CP. Pseudophakic retinal detachments. Retina 1985; 5:1– 4. 3. Brazitikos PD, Androudi S, Christen WG, Stangos NT. Primary pars plana vitrectomy versus scleral buckle surgery for the treatment of pseudophakic retinal detachment: a randomized clinical trial. Retina 2005;25:957– 64. 4. Pocock SJ. Clinical Trials: A Practical Approach. New York: Wiley; 1984:134 – 8.
Dear Editor: We read with interest Ahmadieh et al’s article1 comparing scleral buckling and primary vitrectomy (pars plana vitrectomy [PPV]) without an encircling band for pseudophakic and aphakic retinal detachment (RD) repair. The authors conclude that the 2 approaches yield similar outcomes, based on the fact that there were no statistical differences in the initial retinal reattachment rate between the 2 groups at 6 months (68.2%, SB group; 62.6%, PPV group). The largest series of pseudophakic and aphakic RDs repaired with PPV alone was in Campo et al’s prospective trial, in which the initial reattachment rate was substantially higher, at 88%.2 Other authors have reported initial reattachment rates of 90% and 94%.3,4 One of the main advantages of PPV is that retinal breaks undetected in the preoperative examination often can be seen intraoperatively. Pseudophakic RD has a higher prevalence of missed breaks owing to the smaller size and anterior location of the breaks and the fact that the fundus view may be incomplete due to anterior or posterior capsular fibrosis, cortical remnants, or a small pupil. Careful scleral depression and recognition of the Schlieren phenomenon allow the experienced surgeon to detect unrecognized retinal breaks. Some aspects related to the surgery might account for the relatively low reported initial reattachment rate in Ahmadieh’s PPV group: first, all patients were operated on either by an attending vitreoretinal surgeon or by fellows with at least 6 months’ training. In “Discussion,” the authors acknowledge that the surgeon factor may have had a negative effect on the results. Second, in 67 cases (29.8%) no breaks were detected before surgery; however, the number of cases with breaks detected intraoperatively and repaired with PPV is not mentioned. Third, the authors state that when retinal breaks could not be found, laser was used to create 2 or 3 rows of burns posterior to the entire vitreous base. What was the rationale for this treatment? Lastly, how was subretinal fluid drained when the causative breaks were not detected intraoperatively, because retinotomy was not performed? Clarification of these points is important to judge the relative merits of the 2 approaches compared. VICENTE MARTÍNEZ-CASTILLO, MD ANNA BOIXADERA ESPAX, MD JOSÉ GARCÍA-ARUMÍ, MD Barcelona, Spain References 1. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005; 112:1421–9. 2. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy
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without scleral buckle for pseudophakic retinal detachments. Ophthalmology 1999;106:1811–5, discussion 1816. 3. Martinez-Castillo V, Boixadera A, Verdugo A, García-Arumi J. Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position. Ophthalmology 2005;112:1222– 6. 4. Speicher M, Fu AD, Martin JP, von Fricken MA. Primary vitrectomy alone for repair of retinal detachments following cataract surgery. Retina 2000;20:459 – 64.
Author reply Dear Editor: We thank Dr Martinez-Castillo et al for their interest in our study. Campo et al suggested applying 360° laser photocoagulation in the peripheral retina in cases of pseudophakic retinal detachment undergoing primary vitrectomy without an encircling band.1 We anticipated using this technique in our study protocol only for cases in which the surgeon could not detect any retinal break both before and during surgery.2 We did not need to use this technique because at least one retinal break was found intraoperatively in all cases (even in those eyes with undetected breaks before surgery). Laser photocoagulation was applied only around the retinal break(s). Perfluorocarbon liquid was used for subretinal fluid drainage in the vitrectomy group. Drainage retinotomy was avoided due to its potential complications. HAMID AHMADIEH, MD SIAMAK MORADIAN, MD Tehran, Iran References 1. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Ophthalmology 1999;106:1811–5. 2. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005;112:1421–9.
Dear Editor: We read with interest the article from the Pseudophakic and Aphakic Retinal Detachment Study Group.1 In a prospective randomized study, the authors have reported comparable results from scleral buckling and primary vitrectomy for uncomplicated pseudophakic and aphakic retinal detachment (RD) at 6 months in 225 eyes. Although we agree with the authors that primary vitrectomy can be considered as first-line surgical treatment in cases of pseudophakic and aphakic RD, it would be very useful if the authors could provide some additional information that was not provided in the report. Although a recent study has reported primary vitrectomy without the facedown position for pseudophakic RDs with inferior breaks to be effective in achieving 90% retinal reattachment,2 an inferior-break RD may not be expected to have anatomical results comparable to those of an RD with a superior break.3 So, it would be interesting to know whether the 2 study groups differed significantly in distribution of the breaks. The single-operation anatomic success rate of 62.6% at 6 months in the vitrectomy group seems to be lower than rates of previous reports, including one of ours.4,5 We have found
Letters to the Editor a wide-angle viewing system very useful in finding breaks intraoperatively and wish to know the authors’ experience. Because no break could be detected in 29.8% of the eyes, we would like to know the number of eyes in the vitrectomy group that underwent 2 to 3 rows of 360° endophotocoagulation and also whether this 360° endophotocoagulation correlated with the development of proliferative vitreoretinopathy. We find it surprising that the anisometropia at 6 months after surgery did not differ in the 2 groups. It would be interesting to know the refraction of the fellow eyes (mean and standard deviation) at the beginning of the study. Although accurate measurement of the refraction in eyes with RD may not be possible, knowledge of the refractive correction used by a patient before development of RD and measurement of the change in axial length after surgery can be utilized to compare the surgically induced refractive error in the 2 groups. The preoperative characteristics of the eyes failing to achieve retinal reattachment after a single operation in the 2 groups, patient compliance with either procedure, and total duration of the procedure also can be taken into consideration before selecting each of these options in this group of patients. DEEPENDRA VIKRAM SINGH, MD YOG RAJ SHARMA, MD NIKHIL PAL, MD New Delhi, India References 1. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005;112:1421–9. 2. Martinez-Castillo V, Boixadera A, Verdugo A, Garcia-Arumi J. Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position. Ophthalmology 2005;112:1222– 6. 3. Sharma A, Grigoropoulos V, Williamson TH. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol 2004;88:1372–5. 4. Sharma YR, Karunanithi S, Azad RV, et al. Functional and anatomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand 2005;83:293–7. 5. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Ophthalmology 1999;106:1811–5, discussion 1816.
Author reply Dear Editor: We appreciate Dr Singh et al’s comments concerning our article. We agree about the possible effect of the inferior location of retinal breaks on the anatomic results of retinal detachment surgery.1 The reevaluation of our study data, however, showed that there was no statistically significant difference between the 2 treatment groups regarding the distribution of retinal breaks. At least one retinal break was detected in all eyes intraoperatively in both treatment groups (29.8% refers to the cases in which retinal breaks could not be seen before surgery).2 Hence, no case in the vitrectomy group actually underwent 2 to 3 rows of 360°
endophotocoagulation as anticipated in the study protocol. The Landers contact lens system was used for fundus visualization. The buckle group showed a higher rate of anisometropia after surgery than the vitrectomy group. However, due to a high rate of variability in the refraction of the fellow eye, the statistical analysis did not show a significant difference between the 2 groups. We agree with Dr Singh et al that the measurement of axial length before and after surgery could show the surgically induced refractive error in the 2 treatment groups more precisely. HAMID AHMADIEH, MD SIAMAK MORADIAN, MD Tehran, Iran References 1. Sharma A, Grigoropoulos V, Williamson TH. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthlamol 2004;88:1372–5. 2. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005;112:1421–9.
Ciliary Body Edema Dear Editor: Kawana et al found that ciliary body edema after scleral buckling is greater in eyes treated with an encircling procedure than in eyes treated with segmental buckling alone.1 The authors stated that an encircling band or sponge was used but did not describe the buckle height or tension placed on the encircling element. If a sleeve was used to join the free ends of an encircling band, were the two ends of the band pulled through the sleeve to achieve greater indentation of the retina? Were the study surgeons aiming for a low or high buckle effect in these cases? Were sutures placed in such a way as to maximize or minimize the amount of scleral imbrication? These details would be of great interest to surgeons who perform encircling procedures. Perhaps a future study could include an ultrasonographic description of buckle height. This might help determine whether the risk of ciliary body edema could be minimized by aiming for less indentation with encircling elements. JAY M. STEWART, MD San Francisco, California Reference 1. Kawana K, Okamoto F, Hiraoka T, Oshika T. Ciliary body edema after scleral buckling surgery for rhegmatogenous retinal detachment. Ophthalmology 2006;113:36 – 41.
Author reply Dear Editor: We thank Dr Stewart for his interest in our article, and agree that the buckling height and tension are among the important factors that may influence the degree of ciliary body edema after surgery. In our study, the ciliary body region was investigated with ultrasound biomicroscopy. This device, however, cannot visualize the deeper areas, and thus, the buckle height could not be measured directly. The buckle’s tension is also difficult to evaluate.
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Dear Editor: We read with interest Ahmadieh et al’s article1 comparing scleral buckling and primary vitrectomy (pars plana vitrectomy [PPV]) without an encircling band for pseudophakic and aphakic retinal detachment (RD) repair. The authors conclude that the 2 approaches yield similar outcomes, based on the fact that there were no statistical differences in the initial retinal reattachment rate between the 2 groups at 6 months (68.2%, SB group; 62.6%, PPV group). The largest series of pseudophakic and aphakic RDs repaired with PPV alone was in Campo et al’s prospective trial, in which the initial reattachment rate was substantially higher, at 88%.2 Other authors have reported initial reattachment rates of 90% and 94%.3,4 One of the main advantages of PPV is that retinal breaks undetected in the preoperative examination often can be seen intraoperatively. Pseudophakic RD has a higher prevalence of missed breaks owing to the smaller size and anterior location of the breaks and the fact that the fundus view may be incomplete due to anterior or posterior capsular fibrosis, cortical remnants, or a small pupil. Careful scleral depression and recognition of the Schlieren phenomenon allow the experienced surgeon to detect unrecognized retinal breaks. Some aspects related to the surgery might account for the relatively low reported initial reattachment rate in Ahmadieh’s PPV group: first, all patients were operated on either by an attending vitreoretinal surgeon or by fellows with at least 6 months’ training. In “Discussion,” the authors acknowledge that the surgeon factor may have had a negative effect on the results. Second, in 67 cases (29.8%) no breaks were detected before surgery; however, the number of cases with breaks detected intraoperatively and repaired with PPV is not mentioned. Third, the authors state that when retinal breaks could not be found, laser was used to create 2 or 3 rows of burns posterior to the entire vitreous base. What was the rationale for this treatment? Lastly, how was subretinal fluid drained when the causative breaks were not detected intraoperatively, because retinotomy was not performed? Clarification of these points is important to judge the relative merits of the 2 approaches compared. VICENTE MARTÍNEZ-CASTILLO, MD ANNA BOIXADERA ESPAX, MD JOSÉ GARCÍA-ARUMÍ, MD Barcelona, Spain References 1. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005; 112:1421–9. 2. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy
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without scleral buckle for pseudophakic retinal detachments. Ophthalmology 1999;106:1811–5, discussion 1816. 3. Martinez-Castillo V, Boixadera A, Verdugo A, García-Arumi J. Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position. Ophthalmology 2005;112:1222– 6. 4. Speicher M, Fu AD, Martin JP, von Fricken MA. Primary vitrectomy alone for repair of retinal detachments following cataract surgery. Retina 2000;20:459 – 64.
Author reply Dear Editor: We thank Dr Martinez-Castillo et al for their interest in our study. Campo et al suggested applying 360° laser photocoagulation in the peripheral retina in cases of pseudophakic retinal detachment undergoing primary vitrectomy without an encircling band.1 We anticipated using this technique in our study protocol only for cases in which the surgeon could not detect any retinal break both before and during surgery.2 We did not need to use this technique because at least one retinal break was found intraoperatively in all cases (even in those eyes with undetected breaks before surgery). Laser photocoagulation was applied only around the retinal break(s). Perfluorocarbon liquid was used for subretinal fluid drainage in the vitrectomy group. Drainage retinotomy was avoided due to its potential complications. HAMID AHMADIEH, MD SIAMAK MORADIAN, MD Tehran, Iran References 1. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Ophthalmology 1999;106:1811–5. 2. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005;112:1421–9.
Dear Editor: We read with interest the article from the Pseudophakic and Aphakic Retinal Detachment Study Group.1 In a prospective randomized study, the authors have reported comparable results from scleral buckling and primary vitrectomy for uncomplicated pseudophakic and aphakic retinal detachment (RD) at 6 months in 225 eyes. Although we agree with the authors that primary vitrectomy can be considered as first-line surgical treatment in cases of pseudophakic and aphakic RD, it would be very useful if the authors could provide some additional information that was not provided in the report. Although a recent study has reported primary vitrectomy without the facedown position for pseudophakic RDs with inferior breaks to be effective in achieving 90% retinal reattachment,2 an inferior-break RD may not be expected to have anatomical results comparable to those of an RD with a superior break.3 So, it would be interesting to know whether the 2 study groups differed significantly in distribution of the breaks. The single-operation anatomic success rate of 62.6% at 6 months in the vitrectomy group seems to be lower than rates of previous reports, including one of ours.4,5 We have found
Letters to the Editor a wide-angle viewing system very useful in finding breaks intraoperatively and wish to know the authors’ experience. Because no break could be detected in 29.8% of the eyes, we would like to know the number of eyes in the vitrectomy group that underwent 2 to 3 rows of 360° endophotocoagulation and also whether this 360° endophotocoagulation correlated with the development of proliferative vitreoretinopathy. We find it surprising that the anisometropia at 6 months after surgery did not differ in the 2 groups. It would be interesting to know the refraction of the fellow eyes (mean and standard deviation) at the beginning of the study. Although accurate measurement of the refraction in eyes with RD may not be possible, knowledge of the refractive correction used by a patient before development of RD and measurement of the change in axial length after surgery can be utilized to compare the surgically induced refractive error in the 2 groups. The preoperative characteristics of the eyes failing to achieve retinal reattachment after a single operation in the 2 groups, patient compliance with either procedure, and total duration of the procedure also can be taken into consideration before selecting each of these options in this group of patients. DEEPENDRA VIKRAM SINGH, MD YOG RAJ SHARMA, MD NIKHIL PAL, MD New Delhi, India References 1. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005;112:1421–9. 2. Martinez-Castillo V, Boixadera A, Verdugo A, Garcia-Arumi J. Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position. Ophthalmology 2005;112:1222– 6. 3. Sharma A, Grigoropoulos V, Williamson TH. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol 2004;88:1372–5. 4. Sharma YR, Karunanithi S, Azad RV, et al. Functional and anatomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand 2005;83:293–7. 5. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Ophthalmology 1999;106:1811–5, discussion 1816.
Author reply Dear Editor: We appreciate Dr Singh et al’s comments concerning our article. We agree about the possible effect of the inferior location of retinal breaks on the anatomic results of retinal detachment surgery.1 The reevaluation of our study data, however, showed that there was no statistically significant difference between the 2 treatment groups regarding the distribution of retinal breaks. At least one retinal break was detected in all eyes intraoperatively in both treatment groups (29.8% refers to the cases in which retinal breaks could not be seen before surgery).2 Hence, no case in the vitrectomy group actually underwent 2 to 3 rows of 360°
endophotocoagulation as anticipated in the study protocol. The Landers contact lens system was used for fundus visualization. The buckle group showed a higher rate of anisometropia after surgery than the vitrectomy group. However, due to a high rate of variability in the refraction of the fellow eye, the statistical analysis did not show a significant difference between the 2 groups. We agree with Dr Singh et al that the measurement of axial length before and after surgery could show the surgically induced refractive error in the 2 treatment groups more precisely. HAMID AHMADIEH, MD SIAMAK MORADIAN, MD Tehran, Iran References 1. Sharma A, Grigoropoulos V, Williamson TH. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthlamol 2004;88:1372–5. 2. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005;112:1421–9.
Ciliary Body Edema Dear Editor: Kawana et al found that ciliary body edema after scleral buckling is greater in eyes treated with an encircling procedure than in eyes treated with segmental buckling alone.1 The authors stated that an encircling band or sponge was used but did not describe the buckle height or tension placed on the encircling element. If a sleeve was used to join the free ends of an encircling band, were the two ends of the band pulled through the sleeve to achieve greater indentation of the retina? Were the study surgeons aiming for a low or high buckle effect in these cases? Were sutures placed in such a way as to maximize or minimize the amount of scleral imbrication? These details would be of great interest to surgeons who perform encircling procedures. Perhaps a future study could include an ultrasonographic description of buckle height. This might help determine whether the risk of ciliary body edema could be minimized by aiming for less indentation with encircling elements. JAY M. STEWART, MD San Francisco, California Reference 1. Kawana K, Okamoto F, Hiraoka T, Oshika T. Ciliary body edema after scleral buckling surgery for rhegmatogenous retinal detachment. Ophthalmology 2006;113:36 – 41.
Author reply Dear Editor: We thank Dr Stewart for his interest in our article, and agree that the buckling height and tension are among the important factors that may influence the degree of ciliary body edema after surgery. In our study, the ciliary body region was investigated with ultrasound biomicroscopy. This device, however, cannot visualize the deeper areas, and thus, the buckle height could not be measured directly. The buckle’s tension is also difficult to evaluate.
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