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Subretinal fluid drainage via original retinal breaks for rhegmatogenous retinal detachment
ORIGINAL ARTICLE
Subretinal fluid drainage via original retinal breaks for rhegmatogenous retinal detachment Makoto Yamaguchi, MD, Shinsuke Ataka, MD, Kunihiko Shiraki, MD ABSTRACT ● RÉSUMÉ Objective: To evaluate the outcome of vitrectomy using only original retinal breaks for subretinal fluid (SRF) drainage during the repair of primary rhegmatogenous retinal detachment (RRD). Design: A retrospective consecutive interventional case series. Participants: A consecutive series of 112 eyes of 112 patients. Methods: Patients underwent 23-gauge vitrectomy without the use of posterior retinotomy and perfluorocarbon liquids for uncomplicated primary RRD at Osaka City University Hospital between September 2007 and March 2011. Exclusion criteria included eyes with giant retinal tears, grade C2 or worse proliferative vitreoretinopathy (PVR), ocular trauma, and the presence of other vitreoretinal diseases. Results: Single-operation success rate was 92.9%, whereas final anatomical success rate was 100%. Median visual acuity improved significantly from the preoperative logMAR of 0.51 ⫾ 0.78 to the postoperative logMAR of 0.03 ⫾ 0.26 (p o 0.01). No significant differences were observed for the single-operation success rate between the 62 eyes (95.2%) in which some SRF remained at the end of the operation and the rest of the 50 eyes (90.0%, p ¼ 1.000) in which the SRF had been completely aspirated. Complications included transient intraocular pressure rise (12 eyes, 10.7%), epiretinal membrane (5 eyes, 4.5%), and PVR (1 eye, 0.9%). Ocular hypotony and endophthalmitis were not observed. Conclusions: Uncomplicated primary RRD can be successfully repaired by performing vitrectomy using only the original retinal breaks for SRF drainage. In addition, successful outcomes are not dependent on achieving complete reattachment of the retina throughout the fundus. Objet : Évaluation du résultat de la vitrectomie utilisant seulement les déchirures rétiniennes originales pour le drainage du fluide sous-rétinien (FSR) pendant la réparation d’un décollement rétinien rhegmatogène (DRR) primaire. Nature : Série rétrospective de cas consécutifs d’intervention. Participants : Série consécutive de 112 yeux de 112 patients. Méthodes : Les patients avaient subi une vitrectomie de 23 jauges sans l’utilisation d’une rétinotomie postérieure ni de liquide perfluorocarboné pour un DRR primaire non compliqué, à l’Hôpital universitaire d’Osaka City entre les mois de septembre 2007 et mars 2011. Les critères d’exclusion comprenait les yeux ayant des ruptures rétiniennes géantes, une vitréorétinopathie proliférante de grade C2 ou pire, un trauma oculaire et la présence d’autres maladies vitréorétiniennes. Résultats : Le taux de réussite d’une seule opération était de 92,9 %, alors que le taux de réussite anatomique finale était de 100 %. La moyenne d’acuité visuelle s’est améliorée grandement à partir du logarithme préopératoire de l’angle minimal de résolution (logMAR) de 0,51 ± 0,78 au logMAR postopératoire de 0,03 ± 0,26 (Po0,01). Aucune différence significative n’a été observée pour le taux de réussite d’une seule opération, entre 62 yeux (95,2 %) dans lesquels une partie du FSR étaient demeurée et le reste des yeux, soit 50 (90,0 %, P=1,000) dans lesquels le FSR avait été entièrement aspiré. Les complications comprirent la hausse de pression intraoculaire transitoire (12 yeux, 10,7 %), la membrane épirétinienne (5 yeux, 4,5 %) et la vitréorétinopathie proliférante (1 œil, 0,9 %). L’hypotonie oculaire et l’endophtalmie n’ont pas été observées. Conclusions : Le DRR primaire sans complication peut être réparé par une vitrectomie en utilisant seulement les déchirures rétiniennes originales pour le drainage du FSR. En outre, le succès ne dépend pas de la réussite du rattachement complet de la rétine à travers le fond d’œil.
The aims of vitrectomy for rhegmatogenous retinal detachment (RRD) are to eliminate vitreoretinal traction, reattach the retina, coagulate all of the retinal breaks, replace with intraocular tamponade. Drainage of subretinal fluid (SRF) is normally performed before treating the retinal breaks. When SRF cannot be sufficiently drained via the original retinal breaks, it can be drained via a small posterior retinotomy site. However, posterior retinotomy can cause proliferation and visual field defect.1 Thus, instead of using this procedure, some surgeons have
chosen to remove the SRF through the original breaks with the assistance of heavy perfluorocarbon liquids (PFCLs). In fact, PFCLs have been shown to be useful for unfolding and reattaching the retina during the treatment of giant retinal tears2,3 and proliferative vitreoretinopathy (PVR). Disadvantages reported for this technique include toxicity of the PFCL to the retinal pigment epithelium, photoreceptor cells,4 and cornea.5 In addition, when subretinal PFCLs remain, this can lead to retinal degeneration along with permanent scotomas.6,7
From the Department of Ophthalmology and Visual Sciences, Osaka City University, Graduate School of Medicine, Osaka, Japan
Can J Ophthalmol 2014;49:256–260 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.03.001
Originally received Jun. 23, 2013. Final revision Feb. 28, 2014. Accepted Mar. 3, 2014 Correspondence to Makoto Yamaguchi, MD, Department of Ophthalmology and Visual Sciences, Osaka City University, Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan; [email protected]
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Vitrectomy for rhegmatogenous retinal detachment—Yamaguchi et al. Therefore, the aim of this study was to examine the anatomical and visual outcomes of vitrectomy for primary RRD with incomplete SRF drainage when using preexisting retinal breaks without the use of PFCLs or the performance of posterior retinotomy for SRF drainage.
METHODS We carried out a retrospective case review of the medical charts of 140 consecutive patients who underwent 23gauge transconjunctival vitrectomy to repair their primary RRD. The vitrectomies were performed by 2 vitreoretinal surgeons (M.Y. and S.A.) at Osaka City University Hospital between September 2007 and March 2011. The Institutional Review Board of Osaka City University approved the study, and all patients provided written, informed consent before surgery. All surgeries were performed in accordance with the Declaration of Helsinki. Exclusion criteria included eyes with giant retinal tears, eyes with grade C2 or worse PVR, eyes with RRD secondary to ocular trauma, and the presence of any other vitreoretinal diseases such as macular hole, age-related macular degeneration, diabetic retinopathy, or branch retinal-vein occlusion. All patients received local anesthesia via a sub-Tenon injection of 2% Xylocaine (generic: lidocaine). When patients had cataract or when patients with a clear lens were older than 50 years, lensectomy with phacoemulsification was performed at the same time as the vitrectomy. When the macula was on, an intraocular lens (IOL) was implanted after the lensectomy. When the macula was off, secondary intracapsular IOL implantation was performed as soon as the 20% sulfur hexafluoride (SF6) gas was absorbed and after an accurate axial length was obtained during the macula-on period. Vitrectomy was performed using the Accurus Vitrectomy System (Alcon, Fort Worth, Tex.) with the Dutch Ophthalmic Research Centre (Zuidland, The Netherlands) 23G Cannula System or the Alcon single-step 23G cannula system and Oculus BIOM noncontact wide-angle viewing system (Oculus, Wetzlar, Germany). Transscleral cannulas were placed through the pars plana in the superotemporal, supranasal, and inferotemporal quadrants. In brief, after displacing the conjunctiva with forceps, sclerotomy sites were created 3.0 to 3.5 mm posterior to the limbus using a transconjunctival angled approach. All eyes then underwent a core vitrectomy and peripheral vitreous shaving at the vitreous base, which was assisted by sclera depression. Removal of the vitreous traction on the retinal break was then secured. While fluid–air exchange was performed, the SRF was drained through the original retinal breaks using a back flush needle with a silicone tip. The patient’s face and globe were tilted toward the side of the original retinal breaks to allow gravity to move the SRF to the retinal break side,
where it was then aspirated. The noncontact wide-viewing system made tilting of the face possible. Neither retinotomy nor PFCLs were used, even if bullous SRF still remained. Subsequently, intraocular laser or cryopexy, or both, were used to coagulate only around the retinal breaks. Prophylactic 360-degree endolaser was not performed. At the end of the procedure, 20% SF6 gas was injected and the cannulas were removed. All sclerotomy sites were closed by a 9–0 polyglycolic acid suture. SF6 tamponade was used in all cases. All patients were instructed to maintain a facedown position for 7 days after the surgery. Best corrected visual acuity (BCVA) was measured using the Landolt C visual acuity chart, and the decimal acuities were converted to logMAR units. All patients had an ophthalmological examination at Z3 months after their final surgery. BCVA examinations were performed at 3, 6, 12, and 18 months after the final reattachment. The outcomes evaluated in this study were single-operation anatomical success rate, final anatomical success rate, postoperative BCVA, and surgical complications. Preoperative and postoperative BCVA were compared using a Student t test. A Fisher’s exact test was used for comparisons of the following points: single-operation success rate with regard to the lens status (phakic or pseudophakic), at the time of vitrectomy; retinal break locations at the inferior quadrant or at other quadrants of the fundus; single or multiple retinal breaks; RRD symptom duration before the first operation; and the presence or absence of macular detachment. Statistical significance was defined as a 2-tailed p value less than 0.05.
RESULTS Of the 140 patients evaluated for this study, 112 eyes of 112 patients were considered to be eligible for this study. We excluded patients found to have eyes with giant retinal tears (1 eye), grade C2 or worse PVR (8 eyes), ocular trauma (3 eyes), macular hole (6 eyes), age-related macular degeneration (5 eyes), diabetic retinopathy (3 eyes), and branch retinal-vein occlusion (2 eyes). Table 1 summarizes patient data. The mean duration of symptoms was 11 days (range 1–90 days), with 30 eyes having a duration of symptoms of more than 7 days. The mean follow-up time after the final reattachment was 7.9 months (range 3–18 months). Total retinal detachment was detected in 8 eyes (7.1%). Macula-off retinal detachment was present before surgery in 49 eyes (43.8%). The distributions of the retinal breaks with regard to the quadrants of the fundus are shown in Figure 1. The retinal breaks were located between the ora and the equator in 45 eyes (40.2%), and near the equator in 81 eyes (59.8%), with no retinal breaks observed at the ora serrate or posterior to the equator. As shown in Table 2, the single-operation success rate was 92.9% (104/112 eyes). The final anatomical success CAN J OPHTHALMOL — VOL. 49, NO. 3, JUNE 2014
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Vitrectomy for rhegmatogenous retinal detachment—Yamaguchi et al. Table 1—Preoperative characteristics of patients undergoing vitrectomy Sex, M/F Mean age ⫾ SD Mean duration Mean follow-up period Lens status Clear lens Cataract Pseudophakia Inferior tear Single retinal beak Multiple retinal breaks Extent of retinal detachment r1 quadrant 2 quadrants 3 quadrants 4 quadrants Total Macula off Proliferative vitreoretinopathy
78/34 57 ⫾ 12 y 11 days (range 1–90 days) 8.6 mo (range 3–24 mo) 19 77 16 26 88 24
eyes eyes eyes eyes eyes eyes
(17.0%) (68.8%) (14.3%) (23.2%) (78.6%) (21.4%)
56 eyes 46 eyes 1 eye 1 eye 8 eyes 49 eyes 5 eyes
(50%) (41.1%) (0.9%) (0.9%) (7.1%) (43.8%) (4.5%)
rate was 100.0% (112/112 eyes). At the end of surgery, some SRF remained in 62 eyes (55.4%). The extent of the remaining SRF in these 62 eyes was in 1 quadrant or less in 56 eyes (90.3%) and in 2 quadrants in 6 eyes (9.7%). Slit-lamp biomicroscopy showed there was no apparent SRF remaining in any of the patients on the day that the gas bubble no longer covered the macula. The single operation success rate was not significantly different between the 62 eyes in which some SRF remained at the end of the operation (95.2%) and in the other 50 eyes (90.0%, p ¼ 1.000) in which the SRF had been completely aspirated. Combined lensectomy with IOL placement was performed in 86 eyes (76.8%), of which 62 eyes with the macula-on status had IOL implantation after the lensectomy. Secondary IOL implantation was performed in the remaining 24 macula-off eyes. There were no significant differences in the single-operation success rates between the phakic (93.8%) and pseudophakic (87.5%, p ¼ 1.000) eyes before the surgery, or between the macula-off (95.9%) and macula-on
Fig. 1 — Quadratic distribution of retinal breaks.
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Table 2—Single-operation success rate All patients Subretinal fluid after drainage Remained* None Lens status before surgery Phakic eyes (eyes remained phakic without combined cataract surgery†) Pseudophakic Macula status before surgery Macula-on Macula-off Retinal break(s) Single retinal break Multiple retinal breaks Location of retinal break(s) Inferior quadrant Other quadrants Proliferative vitreoretinopathy
92.9% (104/112 eyes) 95.2% (59/62 eyes) 90.0% (45/50 eyes) 93.8% (90/96 eyes) (100.0% [10/10 eyes]) 87.5% (14/16 eyes) 92.1% (58/63 eyes) 95.9% (47/49 eyes) 93.2% (82/88 eyes) 91.7% (22/24 eyes) 92.3% (24/26 eyes) 93.0% (80/86 eyes) 80.0% (4/5 eyes)
*The 62 eyes for which some subretinal fluid remained at the end of the operation. †Phakic eyes that did not receive combined cataract surgery.
(92.1%, p ¼ 1.000) retinal detachment groups. There was also no significant difference in the single-operation success rate between the eyes with multiple retinal breaks (91.7%) and the eyes with a single retinal break (93.2%, 82/88 eyes, p ¼ 1.000). In addition, there was no significant difference noted for the single-operation success rate between eyes with retinal breaks at the inferior quadrant (92.3%) and the remaining eyes with breaks at other quadrants (93.0%, 80/86 eyes, p ¼ 1.000). For the 8 eyes in which retinal attachment could not be obtained after the primary vitrectomy or in which retinal detachment recurred, untreated retinal breaks were found in 7 eyes (6.3%), whereas there was progression of PVR to grade C3 found in 1 eye (0.9%), which was preoperative grade A PVR. The eye showed progression of PVR after the initial surgery despite having complete aspiration of SRF. The mean logMAR BCVA improved significantly from 0.51 ⫾ 0.78 preoperatively to 0.03 ⫾ 0.26 postoperatively (p o 0.01). As shown in Figure 2, BCVA im-
Fig. 2 — Preoperative and postoperative logMAR visual acuity. The logMAR visual acuity improved significantly from 0.51 ⫾ 0.78 preoperatively to 0.03 ⫾ 0.26 postoperatively in patients undergoing vitrectomy (p o 0.01, paired t test). Visual acuity improved in 92 eyes (82.1%), did not change in 19 eyes (17.0%), and worsened in 1 eye (0.9%).
Vitrectomy for rhegmatogenous retinal detachment—Yamaguchi et al. operation. A total of 3 of 5 patients underwent reoperation for ERM peeling.
DISCUSSION
Fig. 3 — Preoperative and postoperative logMAR visual acuity in macula-on cases with subretinal fluid. BCVA, best corrected visual acuity.
proved in 92 eyes (82.1%), exhibited no change in 19 eyes (17.0%), and worsened in 1 eye (0.9%). The postoperative BCVA improved significantly from the preoperative BCVA in both the macula-on cases (from 0.17 ⫾ 0.57 to –0.07 ⫾ 0.16, p o 0.01) and macula-off cases (from 0.95 ⫾ 0.81 to 0.16 ⫾ 0.29, p o 0.01). As compared with the preoperative BCVA, a significant improvement was especially noted in the postoperative BCVA of the 49 macula-off eyes. This improvement was observed in both the 36 eyes for which SRF remained (from 0.97 ⫾ 0.80 to 0.12 ⫾ 0.22, p o 0.01) and the 13 eyes for which no SRF remained (from 0.90 ⫾ 0.87 to 0.27 ⫾ 0.43, p o 0.01). In the macula-off patients, no significant differences were observed for the postoperative BCVA between the groups with SRF (0.12 ⫾ 0.22) and without any remaining SRF (0.27 ⫾ 0.43; p ¼ 0.243). There was also no difference noted in the macula-on patients for the postoperative BCVA between the groups with SRF (–0.08 ⫾ 0.13) and without any remaining SRF (–0.06 ⫾ 0.18; p ¼ 0.6066). All patients maintained a 7-day prone position after the operation, and slit-lamp biomicroscopy showed no postoperative retinal folds were observed in any patients. Furthermore, an Amsler chart examination revealed no metamorphopsia in the maculaon patients. As shown in Figure 3, there was no worsening of the BCVA after the surgery in any of the macula-on cases with SRF. Table 3 summarizes the intraoperative and postoperative complications. Ocular hypotony (less than 8 mm Hg) and endophthalmitis were not observed. Although transiently increased intraocular pressure was noted in 12 eyes (10.7%), the use of glaucoma eye drops brought the pressure under control within a few days. In the 5 eyes (4.5%) found to have epiretinal membrane (ERM), SRF remained in 1 quadrant or less in 4 of these eyes, whereas the SRF was completely removed in 1 eye after the initial
This study demonstrated that vitrectomy performed using only the original retinal breaks for drainage of SRF without using either posterior retinotomy or PFCLs resulted in adequate single-operation anatomical and final anatomical success rates. Our single-operation anatomical success rate was consistent with other previous reports of small-gauge vitrectomy (74–93.3%) that either used posterior retinotomy for the SRF drainage site or used PFCLs.8–12 Moreover, no significant differences were observed for the single-operation success rate related to the remaining SRF, the lens status, the macula-on or -off status, the location of the retinal breaks, or the single and multiple retinal breaks. Overall, good recovery of the BCVA was also achieved in these patients. These results suggest that posterior retinotomy and PFCLs are not necessarily the best techniques for SRF drainage. However, the findings for our retrospective, nonrandomized, noncontrolled study will need to be further confirmed in a prospective, randomized, controlled trial. In our study, 5 eyes were found to have iatrogenic retinal breaks during the vitreous base shaving. Iatrogenic retinal breaks could be avoided by using PFCLs to stabilize the retina. However, when PFCLs remain subretinally, this was reported to potentially lead to retinal degeneration and permanent scotoma.6,7,13–16 In addition, retained PFCLs can also cause postoperative inflammation16 and secondary glaucoma.17 Moreover, the use of PFCLs can also be a problem because of the increased importance of cutting health care costs. Posterior retinotomy can produce subretinal neovascularization and visual field defects.1 Therefore, our current data suggest it might be best to avoid using these techniques when other options exist. Furthermore, it is empirically known that complete reattachment of the retina throughout the fundus is not necessary, provided the retinal breaks are attached to the RPE after laser or cryo retinopexy. Although to the best of our knowledge there has yet to be any reported proof for this therapeutic approach, the results of our study do support these empirical guidelines. Retinal folds that are caused by persistent SRF can also be a risk for visual acuity loss or metamorphopsia. Chronic SRF can be more viscous, and if left behind, it may be Table 3—Intraoperative and postoperative complications Intraoperative retinal breaks Hypotony Secondary glaucoma Secondary epiretinal membrane Endophthalmitis Retinal detachment relapse Proliferative vitreoretinopathy
5 eyes 0 eyes 12 eyes 5 eyes 0 eyes 8 eyes 1 eye
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(4.5%) (0%) (10.7%) (4.5%) (0%) (7.1%) (0.9%)
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Vitrectomy for rhegmatogenous retinal detachment—Yamaguchi et al. more difficult for the RPE to reabsorb. Thus, some surgeons use PFCLs or perform posterior retinotomy to ensure this will not become a problem. However, we believe that both gas tamponade and gravity further assisted in the removal of the remaining SRF via the original tears. It is also possible some of the remaining SRF could have been pumped out by the RPE after the operations. Furthermore, we believe that most of chronic SRF is exchanged for balanced salt solution when there is thorough aspiration during the operation. One of the limitations of our study was the lack of any optical coherence tomography examinations. However, we found no significant differences in the postoperative BCVA between the cases with SRF and the cases without any remaining SRF in the macula-off cases. Furthermore, there were also no significant differences in the postoperative BCVA between the cases with and without any remaining SRF in the macula-on patients. In addition, metamorphopsia and a reduction of the visual acuity did not occur after surgery in any of the macula-on cases with SRF. In our study, we found that the incision-site sutures helped prevent hypotony and endophthalmitis. Because the possibility exists that the SRF could promote an inflammatory reaction and cause proliferation of the retinal glial and RPE cells,18,19 there is a potential risk that the remaining SRF might induce ERM and PVR. Thus, we believe that it is better to drain as much of the SRF as possible. However, in contrast with other previous reports,8–12,20,21 our study found only a low incidence of ERM (4.5%) and PVR (0.9%). Although the SRF was completely drained during the operations in the current cases, 1 eye did show PVR progression. On further examination, this patient was found to have preoperative PVR as a risk factor.22,23 In conclusion, current results suggest uncomplicated primary RRD can be successfully repaired by performing vitrectomy using only the original retinal breaks for SRF drainage. In addition, as our findings demonstrated that it was not absolutely necessary to achieve complete reattachment of the retina throughout the fundus during the operation, this suggests there is a lesser need to perform posterior retinotomy and use PFCLs than previously thought. However, it might be necessary to use the facedown positioning for macular reattachment in cases without complete SRF drainage.
Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. REFERENCES 1. McDonald HR, Lewis H, Aaberg TM, Abrams GW. Complications of endodrainage retinotomies created during vitreous surgery for complicated retinal detachment. Ophthalmology. 1989;96:358-63.
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2. Chang S, Lincoff H, Zimmerman NJ, Fuchs W. Giant retinal tears. Surgical techniques and results using perfluorocarbon liquids. Arch Ophthalmol. 1989;107:761-6. 3. Verstraeten T, Williams GA, Chang S, et al. Lens-sparing vitrectomy with perfluorocarbon liquid for the primary treatment of giant retinal tears. Ophthalmology. 1995;102:17-20. 4. Berglin L, Ren J, Algvere PV. Retinal detachment and degeneration in response to subretinal perfluorodecaline in rabbit eyes. Graefes Arch Clin Exp Ophthalmol. 1993;231:233-7. 5. Cauchi P, Azuara-Blanco A, McKenzie J. Corneal toxicity and inflammation secondary to retained perfluorodecalin. Am J Ophthalmol. 2005;140:322-3. 6. Tewari A, Eliott D, Singh CN, Garcia-Valenzuela E, Ito Y, Abrams GW. Changes in retinal sensitivity from retained subretinal perfluorocarbon liquid. Retina. 2009;29:248-50. 7. Lesnoni G, Rossi T, Gelso A. Subfoveal liquid perfluorocarbon. Retina. 2004;24:172-6. 8. Lai MM, Ruby AJ, Sarrafizadeh R, et al. Repair of primary rhegmatogenous retinal detachment using 25-gauge transconjunctival sutureless vitrectomy. Retina. 2008;28:729-34. 9. Miller DM, Riemann CD, Foster RE, Petersen MR. Primary repair of retinal detachment with 25-gauge pars plana vitrectomy. Retina. 2008;28:931-6. 10. Mura M, Tan SH, De Smet MD. Use of 25-gauge vitrectomy in the management of primary rhegmatogenous retinal detachment. Retina. 2009;29:1299-304. 11. Albrieux M, Rouberol F, Bernheim D, Romanet JP, Chiquet C. Comparative study of 23-gauge vitrectomy versus 20-gauge vitrectomy for the treatment of rhegmatogenous retinal detachment. Graefes Arch Clin Exp Ophthalmol. 2011;249:1459-68. 12. Kobayashi S, Sato S, Inoue M, et al. Comparison of 20- and 25gauge vitrectomy for primary repair of rhegmatogenous retinal detachment. Ophthalmic Surg Lasers Imaging. 2010;41:550-4. 13. Loewenstein A, Humayum MS, de Juan E Jr, Campochiaro PA, Haller JA. Perfluoroperhydrophenantrene versus perfluoro-n-octane in vitreoretinal surgery. Ophthalmology. 2000;107:1078-82. 14. Scott IU, Murray TG, Flynn HW, Smiddy WE, Feuer WJ, Schiffman JC. Outcomes and complications associated with perfluoron-octane and perfluoroperhydrophenanthrene in complex retinal detachment repair. Ophthalmology. 2000;107:860-5. 15. Cohen SY, Dubois L, Elmaleh C. Retinal hole as a complication of long-standing subretinal perfluorocarbon liquid. Retina. 2006;26: 843-4. 16. Elsing SH, Fekrat S, Green WR, Chang S, Wajer SD, Haller JA. Clinicopathologic findings in eyes with retained perfluoro-n-octane liquid. Ophthalmology. 2001;108:45-8. 17. Toffoli D, Arbour JD, Harasymowycz P. Retained perfluoron postvitreoretinal surgery causing secondary open-angle glaucoma. Can J Ophthalmol. 2008;43:372. 18. Quintyn JC, Brasseur G. Subretinal fluid in primary rhegmatogenous retinal detachment: physiopathology and composition. Surv Ophthalmol. 2004;49:96-108. 19. Hirase K, Sugiyama T, Ikeda T, et al. Transforming growth factor-2 increases in subretinal fluid in rhegmatogenous retinal detachment with subretinal strands. Ophthalmologica. 2005;219:222-5. 20. Katrira RC, Zamani M, Berinstein DM, Garfinkel RA. Incidence and characteristics of macular pucker formation after primary retinal detachment repair by pars plana vitrectomy alone. Retina. 2008;28: 744-8. 21. Theodossiadis PG, Theodossiadis GP, Charonis A, Emfietzoglou I, Grigoropoulous VG, Liarakos VS. The photoreceptor layer as a prognostic factor for visual acuity in secondary epiretinal membrane after retinal detachment surgery: imaging analysis by spectral-domain optical coherence tomography. Am J Ophthalmol. 2011;151: 973-80. 22. Yoshino Y, Ideta H, Nagasaki H, Uemura A. Comparative study of clinical factors predisposing patients to proliferative vitreoretinopathy. Retina. 1989;9:97-100. 23. Girard P, Mimoun G, Karpouzas I, Montefiore G. Clinical risk factors for proliferative vitreoretinopathy after retinal detachment surgery. Retina. 1994;14:417-24.
Subretinal fluid drainage via original retinal breaks for rhegmatogenous retinal detachment Makoto Yamaguchi, MD, Shinsuke Ataka, MD, Kunihiko Shiraki, MD ABSTRACT ● RÉSUMÉ Objective: To evaluate the outcome of vitrectomy using only original retinal breaks for subretinal fluid (SRF) drainage during the repair of primary rhegmatogenous retinal detachment (RRD). Design: A retrospective consecutive interventional case series. Participants: A consecutive series of 112 eyes of 112 patients. Methods: Patients underwent 23-gauge vitrectomy without the use of posterior retinotomy and perfluorocarbon liquids for uncomplicated primary RRD at Osaka City University Hospital between September 2007 and March 2011. Exclusion criteria included eyes with giant retinal tears, grade C2 or worse proliferative vitreoretinopathy (PVR), ocular trauma, and the presence of other vitreoretinal diseases. Results: Single-operation success rate was 92.9%, whereas final anatomical success rate was 100%. Median visual acuity improved significantly from the preoperative logMAR of 0.51 ⫾ 0.78 to the postoperative logMAR of 0.03 ⫾ 0.26 (p o 0.01). No significant differences were observed for the single-operation success rate between the 62 eyes (95.2%) in which some SRF remained at the end of the operation and the rest of the 50 eyes (90.0%, p ¼ 1.000) in which the SRF had been completely aspirated. Complications included transient intraocular pressure rise (12 eyes, 10.7%), epiretinal membrane (5 eyes, 4.5%), and PVR (1 eye, 0.9%). Ocular hypotony and endophthalmitis were not observed. Conclusions: Uncomplicated primary RRD can be successfully repaired by performing vitrectomy using only the original retinal breaks for SRF drainage. In addition, successful outcomes are not dependent on achieving complete reattachment of the retina throughout the fundus. Objet : Évaluation du résultat de la vitrectomie utilisant seulement les déchirures rétiniennes originales pour le drainage du fluide sous-rétinien (FSR) pendant la réparation d’un décollement rétinien rhegmatogène (DRR) primaire. Nature : Série rétrospective de cas consécutifs d’intervention. Participants : Série consécutive de 112 yeux de 112 patients. Méthodes : Les patients avaient subi une vitrectomie de 23 jauges sans l’utilisation d’une rétinotomie postérieure ni de liquide perfluorocarboné pour un DRR primaire non compliqué, à l’Hôpital universitaire d’Osaka City entre les mois de septembre 2007 et mars 2011. Les critères d’exclusion comprenait les yeux ayant des ruptures rétiniennes géantes, une vitréorétinopathie proliférante de grade C2 ou pire, un trauma oculaire et la présence d’autres maladies vitréorétiniennes. Résultats : Le taux de réussite d’une seule opération était de 92,9 %, alors que le taux de réussite anatomique finale était de 100 %. La moyenne d’acuité visuelle s’est améliorée grandement à partir du logarithme préopératoire de l’angle minimal de résolution (logMAR) de 0,51 ± 0,78 au logMAR postopératoire de 0,03 ± 0,26 (Po0,01). Aucune différence significative n’a été observée pour le taux de réussite d’une seule opération, entre 62 yeux (95,2 %) dans lesquels une partie du FSR étaient demeurée et le reste des yeux, soit 50 (90,0 %, P=1,000) dans lesquels le FSR avait été entièrement aspiré. Les complications comprirent la hausse de pression intraoculaire transitoire (12 yeux, 10,7 %), la membrane épirétinienne (5 yeux, 4,5 %) et la vitréorétinopathie proliférante (1 œil, 0,9 %). L’hypotonie oculaire et l’endophtalmie n’ont pas été observées. Conclusions : Le DRR primaire sans complication peut être réparé par une vitrectomie en utilisant seulement les déchirures rétiniennes originales pour le drainage du FSR. En outre, le succès ne dépend pas de la réussite du rattachement complet de la rétine à travers le fond d’œil.
The aims of vitrectomy for rhegmatogenous retinal detachment (RRD) are to eliminate vitreoretinal traction, reattach the retina, coagulate all of the retinal breaks, replace with intraocular tamponade. Drainage of subretinal fluid (SRF) is normally performed before treating the retinal breaks. When SRF cannot be sufficiently drained via the original retinal breaks, it can be drained via a small posterior retinotomy site. However, posterior retinotomy can cause proliferation and visual field defect.1 Thus, instead of using this procedure, some surgeons have
chosen to remove the SRF through the original breaks with the assistance of heavy perfluorocarbon liquids (PFCLs). In fact, PFCLs have been shown to be useful for unfolding and reattaching the retina during the treatment of giant retinal tears2,3 and proliferative vitreoretinopathy (PVR). Disadvantages reported for this technique include toxicity of the PFCL to the retinal pigment epithelium, photoreceptor cells,4 and cornea.5 In addition, when subretinal PFCLs remain, this can lead to retinal degeneration along with permanent scotomas.6,7
From the Department of Ophthalmology and Visual Sciences, Osaka City University, Graduate School of Medicine, Osaka, Japan
Can J Ophthalmol 2014;49:256–260 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.03.001
Originally received Jun. 23, 2013. Final revision Feb. 28, 2014. Accepted Mar. 3, 2014 Correspondence to Makoto Yamaguchi, MD, Department of Ophthalmology and Visual Sciences, Osaka City University, Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan; [email protected]
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Vitrectomy for rhegmatogenous retinal detachment—Yamaguchi et al. Therefore, the aim of this study was to examine the anatomical and visual outcomes of vitrectomy for primary RRD with incomplete SRF drainage when using preexisting retinal breaks without the use of PFCLs or the performance of posterior retinotomy for SRF drainage.
METHODS We carried out a retrospective case review of the medical charts of 140 consecutive patients who underwent 23gauge transconjunctival vitrectomy to repair their primary RRD. The vitrectomies were performed by 2 vitreoretinal surgeons (M.Y. and S.A.) at Osaka City University Hospital between September 2007 and March 2011. The Institutional Review Board of Osaka City University approved the study, and all patients provided written, informed consent before surgery. All surgeries were performed in accordance with the Declaration of Helsinki. Exclusion criteria included eyes with giant retinal tears, eyes with grade C2 or worse PVR, eyes with RRD secondary to ocular trauma, and the presence of any other vitreoretinal diseases such as macular hole, age-related macular degeneration, diabetic retinopathy, or branch retinal-vein occlusion. All patients received local anesthesia via a sub-Tenon injection of 2% Xylocaine (generic: lidocaine). When patients had cataract or when patients with a clear lens were older than 50 years, lensectomy with phacoemulsification was performed at the same time as the vitrectomy. When the macula was on, an intraocular lens (IOL) was implanted after the lensectomy. When the macula was off, secondary intracapsular IOL implantation was performed as soon as the 20% sulfur hexafluoride (SF6) gas was absorbed and after an accurate axial length was obtained during the macula-on period. Vitrectomy was performed using the Accurus Vitrectomy System (Alcon, Fort Worth, Tex.) with the Dutch Ophthalmic Research Centre (Zuidland, The Netherlands) 23G Cannula System or the Alcon single-step 23G cannula system and Oculus BIOM noncontact wide-angle viewing system (Oculus, Wetzlar, Germany). Transscleral cannulas were placed through the pars plana in the superotemporal, supranasal, and inferotemporal quadrants. In brief, after displacing the conjunctiva with forceps, sclerotomy sites were created 3.0 to 3.5 mm posterior to the limbus using a transconjunctival angled approach. All eyes then underwent a core vitrectomy and peripheral vitreous shaving at the vitreous base, which was assisted by sclera depression. Removal of the vitreous traction on the retinal break was then secured. While fluid–air exchange was performed, the SRF was drained through the original retinal breaks using a back flush needle with a silicone tip. The patient’s face and globe were tilted toward the side of the original retinal breaks to allow gravity to move the SRF to the retinal break side,
where it was then aspirated. The noncontact wide-viewing system made tilting of the face possible. Neither retinotomy nor PFCLs were used, even if bullous SRF still remained. Subsequently, intraocular laser or cryopexy, or both, were used to coagulate only around the retinal breaks. Prophylactic 360-degree endolaser was not performed. At the end of the procedure, 20% SF6 gas was injected and the cannulas were removed. All sclerotomy sites were closed by a 9–0 polyglycolic acid suture. SF6 tamponade was used in all cases. All patients were instructed to maintain a facedown position for 7 days after the surgery. Best corrected visual acuity (BCVA) was measured using the Landolt C visual acuity chart, and the decimal acuities were converted to logMAR units. All patients had an ophthalmological examination at Z3 months after their final surgery. BCVA examinations were performed at 3, 6, 12, and 18 months after the final reattachment. The outcomes evaluated in this study were single-operation anatomical success rate, final anatomical success rate, postoperative BCVA, and surgical complications. Preoperative and postoperative BCVA were compared using a Student t test. A Fisher’s exact test was used for comparisons of the following points: single-operation success rate with regard to the lens status (phakic or pseudophakic), at the time of vitrectomy; retinal break locations at the inferior quadrant or at other quadrants of the fundus; single or multiple retinal breaks; RRD symptom duration before the first operation; and the presence or absence of macular detachment. Statistical significance was defined as a 2-tailed p value less than 0.05.
RESULTS Of the 140 patients evaluated for this study, 112 eyes of 112 patients were considered to be eligible for this study. We excluded patients found to have eyes with giant retinal tears (1 eye), grade C2 or worse PVR (8 eyes), ocular trauma (3 eyes), macular hole (6 eyes), age-related macular degeneration (5 eyes), diabetic retinopathy (3 eyes), and branch retinal-vein occlusion (2 eyes). Table 1 summarizes patient data. The mean duration of symptoms was 11 days (range 1–90 days), with 30 eyes having a duration of symptoms of more than 7 days. The mean follow-up time after the final reattachment was 7.9 months (range 3–18 months). Total retinal detachment was detected in 8 eyes (7.1%). Macula-off retinal detachment was present before surgery in 49 eyes (43.8%). The distributions of the retinal breaks with regard to the quadrants of the fundus are shown in Figure 1. The retinal breaks were located between the ora and the equator in 45 eyes (40.2%), and near the equator in 81 eyes (59.8%), with no retinal breaks observed at the ora serrate or posterior to the equator. As shown in Table 2, the single-operation success rate was 92.9% (104/112 eyes). The final anatomical success CAN J OPHTHALMOL — VOL. 49, NO. 3, JUNE 2014
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Vitrectomy for rhegmatogenous retinal detachment—Yamaguchi et al. Table 1—Preoperative characteristics of patients undergoing vitrectomy Sex, M/F Mean age ⫾ SD Mean duration Mean follow-up period Lens status Clear lens Cataract Pseudophakia Inferior tear Single retinal beak Multiple retinal breaks Extent of retinal detachment r1 quadrant 2 quadrants 3 quadrants 4 quadrants Total Macula off Proliferative vitreoretinopathy
78/34 57 ⫾ 12 y 11 days (range 1–90 days) 8.6 mo (range 3–24 mo) 19 77 16 26 88 24
eyes eyes eyes eyes eyes eyes
(17.0%) (68.8%) (14.3%) (23.2%) (78.6%) (21.4%)
56 eyes 46 eyes 1 eye 1 eye 8 eyes 49 eyes 5 eyes
(50%) (41.1%) (0.9%) (0.9%) (7.1%) (43.8%) (4.5%)
rate was 100.0% (112/112 eyes). At the end of surgery, some SRF remained in 62 eyes (55.4%). The extent of the remaining SRF in these 62 eyes was in 1 quadrant or less in 56 eyes (90.3%) and in 2 quadrants in 6 eyes (9.7%). Slit-lamp biomicroscopy showed there was no apparent SRF remaining in any of the patients on the day that the gas bubble no longer covered the macula. The single operation success rate was not significantly different between the 62 eyes in which some SRF remained at the end of the operation (95.2%) and in the other 50 eyes (90.0%, p ¼ 1.000) in which the SRF had been completely aspirated. Combined lensectomy with IOL placement was performed in 86 eyes (76.8%), of which 62 eyes with the macula-on status had IOL implantation after the lensectomy. Secondary IOL implantation was performed in the remaining 24 macula-off eyes. There were no significant differences in the single-operation success rates between the phakic (93.8%) and pseudophakic (87.5%, p ¼ 1.000) eyes before the surgery, or between the macula-off (95.9%) and macula-on
Fig. 1 — Quadratic distribution of retinal breaks.
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Table 2—Single-operation success rate All patients Subretinal fluid after drainage Remained* None Lens status before surgery Phakic eyes (eyes remained phakic without combined cataract surgery†) Pseudophakic Macula status before surgery Macula-on Macula-off Retinal break(s) Single retinal break Multiple retinal breaks Location of retinal break(s) Inferior quadrant Other quadrants Proliferative vitreoretinopathy
92.9% (104/112 eyes) 95.2% (59/62 eyes) 90.0% (45/50 eyes) 93.8% (90/96 eyes) (100.0% [10/10 eyes]) 87.5% (14/16 eyes) 92.1% (58/63 eyes) 95.9% (47/49 eyes) 93.2% (82/88 eyes) 91.7% (22/24 eyes) 92.3% (24/26 eyes) 93.0% (80/86 eyes) 80.0% (4/5 eyes)
*The 62 eyes for which some subretinal fluid remained at the end of the operation. †Phakic eyes that did not receive combined cataract surgery.
(92.1%, p ¼ 1.000) retinal detachment groups. There was also no significant difference in the single-operation success rate between the eyes with multiple retinal breaks (91.7%) and the eyes with a single retinal break (93.2%, 82/88 eyes, p ¼ 1.000). In addition, there was no significant difference noted for the single-operation success rate between eyes with retinal breaks at the inferior quadrant (92.3%) and the remaining eyes with breaks at other quadrants (93.0%, 80/86 eyes, p ¼ 1.000). For the 8 eyes in which retinal attachment could not be obtained after the primary vitrectomy or in which retinal detachment recurred, untreated retinal breaks were found in 7 eyes (6.3%), whereas there was progression of PVR to grade C3 found in 1 eye (0.9%), which was preoperative grade A PVR. The eye showed progression of PVR after the initial surgery despite having complete aspiration of SRF. The mean logMAR BCVA improved significantly from 0.51 ⫾ 0.78 preoperatively to 0.03 ⫾ 0.26 postoperatively (p o 0.01). As shown in Figure 2, BCVA im-
Fig. 2 — Preoperative and postoperative logMAR visual acuity. The logMAR visual acuity improved significantly from 0.51 ⫾ 0.78 preoperatively to 0.03 ⫾ 0.26 postoperatively in patients undergoing vitrectomy (p o 0.01, paired t test). Visual acuity improved in 92 eyes (82.1%), did not change in 19 eyes (17.0%), and worsened in 1 eye (0.9%).
Vitrectomy for rhegmatogenous retinal detachment—Yamaguchi et al. operation. A total of 3 of 5 patients underwent reoperation for ERM peeling.
DISCUSSION
Fig. 3 — Preoperative and postoperative logMAR visual acuity in macula-on cases with subretinal fluid. BCVA, best corrected visual acuity.
proved in 92 eyes (82.1%), exhibited no change in 19 eyes (17.0%), and worsened in 1 eye (0.9%). The postoperative BCVA improved significantly from the preoperative BCVA in both the macula-on cases (from 0.17 ⫾ 0.57 to –0.07 ⫾ 0.16, p o 0.01) and macula-off cases (from 0.95 ⫾ 0.81 to 0.16 ⫾ 0.29, p o 0.01). As compared with the preoperative BCVA, a significant improvement was especially noted in the postoperative BCVA of the 49 macula-off eyes. This improvement was observed in both the 36 eyes for which SRF remained (from 0.97 ⫾ 0.80 to 0.12 ⫾ 0.22, p o 0.01) and the 13 eyes for which no SRF remained (from 0.90 ⫾ 0.87 to 0.27 ⫾ 0.43, p o 0.01). In the macula-off patients, no significant differences were observed for the postoperative BCVA between the groups with SRF (0.12 ⫾ 0.22) and without any remaining SRF (0.27 ⫾ 0.43; p ¼ 0.243). There was also no difference noted in the macula-on patients for the postoperative BCVA between the groups with SRF (–0.08 ⫾ 0.13) and without any remaining SRF (–0.06 ⫾ 0.18; p ¼ 0.6066). All patients maintained a 7-day prone position after the operation, and slit-lamp biomicroscopy showed no postoperative retinal folds were observed in any patients. Furthermore, an Amsler chart examination revealed no metamorphopsia in the maculaon patients. As shown in Figure 3, there was no worsening of the BCVA after the surgery in any of the macula-on cases with SRF. Table 3 summarizes the intraoperative and postoperative complications. Ocular hypotony (less than 8 mm Hg) and endophthalmitis were not observed. Although transiently increased intraocular pressure was noted in 12 eyes (10.7%), the use of glaucoma eye drops brought the pressure under control within a few days. In the 5 eyes (4.5%) found to have epiretinal membrane (ERM), SRF remained in 1 quadrant or less in 4 of these eyes, whereas the SRF was completely removed in 1 eye after the initial
This study demonstrated that vitrectomy performed using only the original retinal breaks for drainage of SRF without using either posterior retinotomy or PFCLs resulted in adequate single-operation anatomical and final anatomical success rates. Our single-operation anatomical success rate was consistent with other previous reports of small-gauge vitrectomy (74–93.3%) that either used posterior retinotomy for the SRF drainage site or used PFCLs.8–12 Moreover, no significant differences were observed for the single-operation success rate related to the remaining SRF, the lens status, the macula-on or -off status, the location of the retinal breaks, or the single and multiple retinal breaks. Overall, good recovery of the BCVA was also achieved in these patients. These results suggest that posterior retinotomy and PFCLs are not necessarily the best techniques for SRF drainage. However, the findings for our retrospective, nonrandomized, noncontrolled study will need to be further confirmed in a prospective, randomized, controlled trial. In our study, 5 eyes were found to have iatrogenic retinal breaks during the vitreous base shaving. Iatrogenic retinal breaks could be avoided by using PFCLs to stabilize the retina. However, when PFCLs remain subretinally, this was reported to potentially lead to retinal degeneration and permanent scotoma.6,7,13–16 In addition, retained PFCLs can also cause postoperative inflammation16 and secondary glaucoma.17 Moreover, the use of PFCLs can also be a problem because of the increased importance of cutting health care costs. Posterior retinotomy can produce subretinal neovascularization and visual field defects.1 Therefore, our current data suggest it might be best to avoid using these techniques when other options exist. Furthermore, it is empirically known that complete reattachment of the retina throughout the fundus is not necessary, provided the retinal breaks are attached to the RPE after laser or cryo retinopexy. Although to the best of our knowledge there has yet to be any reported proof for this therapeutic approach, the results of our study do support these empirical guidelines. Retinal folds that are caused by persistent SRF can also be a risk for visual acuity loss or metamorphopsia. Chronic SRF can be more viscous, and if left behind, it may be Table 3—Intraoperative and postoperative complications Intraoperative retinal breaks Hypotony Secondary glaucoma Secondary epiretinal membrane Endophthalmitis Retinal detachment relapse Proliferative vitreoretinopathy
5 eyes 0 eyes 12 eyes 5 eyes 0 eyes 8 eyes 1 eye
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(4.5%) (0%) (10.7%) (4.5%) (0%) (7.1%) (0.9%)
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Vitrectomy for rhegmatogenous retinal detachment—Yamaguchi et al. more difficult for the RPE to reabsorb. Thus, some surgeons use PFCLs or perform posterior retinotomy to ensure this will not become a problem. However, we believe that both gas tamponade and gravity further assisted in the removal of the remaining SRF via the original tears. It is also possible some of the remaining SRF could have been pumped out by the RPE after the operations. Furthermore, we believe that most of chronic SRF is exchanged for balanced salt solution when there is thorough aspiration during the operation. One of the limitations of our study was the lack of any optical coherence tomography examinations. However, we found no significant differences in the postoperative BCVA between the cases with SRF and the cases without any remaining SRF in the macula-off cases. Furthermore, there were also no significant differences in the postoperative BCVA between the cases with and without any remaining SRF in the macula-on patients. In addition, metamorphopsia and a reduction of the visual acuity did not occur after surgery in any of the macula-on cases with SRF. In our study, we found that the incision-site sutures helped prevent hypotony and endophthalmitis. Because the possibility exists that the SRF could promote an inflammatory reaction and cause proliferation of the retinal glial and RPE cells,18,19 there is a potential risk that the remaining SRF might induce ERM and PVR. Thus, we believe that it is better to drain as much of the SRF as possible. However, in contrast with other previous reports,8–12,20,21 our study found only a low incidence of ERM (4.5%) and PVR (0.9%). Although the SRF was completely drained during the operations in the current cases, 1 eye did show PVR progression. On further examination, this patient was found to have preoperative PVR as a risk factor.22,23 In conclusion, current results suggest uncomplicated primary RRD can be successfully repaired by performing vitrectomy using only the original retinal breaks for SRF drainage. In addition, as our findings demonstrated that it was not absolutely necessary to achieve complete reattachment of the retina throughout the fundus during the operation, this suggests there is a lesser need to perform posterior retinotomy and use PFCLs than previously thought. However, it might be necessary to use the facedown positioning for macular reattachment in cases without complete SRF drainage.
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