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ORIGINAL ARTICLE
Year : 2021  |  Volume : 28  |  Issue : 2  |  Page : 65-70  

Scleral buckle versus pars plana vitrectomy in the management of primary chronic rhegmatogenous retinal detachment: A comparison of anatomical and visual outcomes


1 Vitreoretinal Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; Department of Ophthalmology, Salmaniya Medical Complex, Manama, Bahrain
2 Department of Research, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
3 Vitreoretinal Division, King Khaled Eye Specialist Hospital, Riyadh; Department of Ophthalmology, Prince Mansour, Military Hospital, Taif, Saudi Arabia
4 Vitreoretinal Division, King Khaled Eye Specialist Hospital, Riyadh; Vitreoretinal Division, Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia
5 Vitreoretinal Division, King Khaled Eye Specialist Hospital; Department of Ophthalmology, King Fahad Medical City, Riyadh, Saudi Arabia

Date of Submission03-Oct-2020
Date of Acceptance08-Aug-2021
Date of Web Publication25-Sep-2021

Correspondence Address:
Dr. Maryam Bunajem
Vitreoretinal Division, King Khaled Eye Specialist Hospital, Al-Oruba Street, PO Box 7191, 51 Riyadh 11462, 51

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/meajo.MEAJO_441_20

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   Abstract 


PURPOSE: The purpose of this study is to compare the anatomical and visual outcomes of scleral buckle (SB) surgery with the pars plana vitrectomy (PPV) in the management of chronic rhegmatogenous retinal detachment.
METHODS: This cohort study included patients who underwent surgical repair SB group and PPV group for chronic retinal detachment during 2014–2018 at the King Khalid Eye Specialist Hospital, Riyadh. The anatomical and functional success rate at 12 months after surgery was compared in two groups. Cox regression and linear regression analysis were performed to identify the predictor of anatomical and functional outcomes, respectively. Need for second surgery was also evaluated.
RESULTS: Our cohort had 68 eyes in SB and 64 eyes in PPV group. Eyes that underwent PPV were more likely to develop retinal detachment over 12 months than those that underwent SB surgery (adjusted heart rates 2.11, 95% confidence interval [CI], 0.95–4.64 P = 0.065). A multivariable linear regression analysis did not reveal a significant association between the surgery type and change in visual acuity (beta coefficient, 0.002; 95% CI,−0.184, 0.189 for specific bread volume; P = 0.979). A higher percentage of eyes in the PPV group compared with those in the SB surgery group required secondary surgery (39.1% vs. 22.1%; P = 0.034).
CONCLUSION: Scleral buckling surgery showed a better single surgery anatomic success rate as compared to PPV in the management of chronic primary rhegmatogenous retinal detachment. The functional outcome of the two procedures was comparable.

Keywords: Anatomical outcome, chronic rhegmatogenous retinal detachment, pars plana vitrectomy, scleral buckle, single surgery, subretinal band, success rate, visual outcome


How to cite this article:
Bunajem M, Ahmad K, Al Zaidi N, Al Bloushi B, Al Zahrani Y. Scleral buckle versus pars plana vitrectomy in the management of primary chronic rhegmatogenous retinal detachment: A comparison of anatomical and visual outcomes. Middle East Afr J Ophthalmol 2021;28:65-70

How to cite this URL:
Bunajem M, Ahmad K, Al Zaidi N, Al Bloushi B, Al Zahrani Y. Scleral buckle versus pars plana vitrectomy in the management of primary chronic rhegmatogenous retinal detachment: A comparison of anatomical and visual outcomes. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2021 Oct 26];28:65-70. Available from: http://www.meajo.org/text.asp?2021/28/2/65/326669




   Introduction Top


Patients with chronic rhegmatogenous retinal detachment (RRD) usually present with advanced disease – the insidious onset of symptoms often go unrecognized by the patients. The vision prognosis after surgery is guarded and patients require regular long-term follow-up.[1] Proliferative vitreoretinopathy (PVR) is present in about 5%–10% of all chronic RRD cases and accounts for more than two-thirds of all retinal re-detachments after surgery.[2]

Several surgical techniques have been used to treat RRD. Of these, scleral buckle (SB) surgery and pars plana vitrectomy (PPV) both have a very high anatomical success rate (>90%).[3] Chronic RRD with severe PVR is particularly challenging to treat.[4] Several studies have compared SB surgery and primary vitrectomy in medium complexity retinal detachment.[4],[5] However, only a limited number of studies have compared different surgical techniques in PVR-complicated chronic RRD. These studies have reported divergent results.[6] Furthermore, even fewer studies have compared the outcomes of SB surgery with vitrectomy alone in chronic RRD.[3],[7] In this study, we assessed the anatomic and visual outcomes of these two procedures in eyes with primary chronic RRD in a large eye care tertiary referral center in the Kingdom of Saudi Arabia.


   Methods Top


This cohort study was conducted in 2019 at the King Khalid Eye Specialist Hospital (KKESH), Riyadh, the largest ophthalmic tertiary referral center in the Kingdom of Saudi Arabia. We included patients aged ≥ 15 years who underwent PPV or SB surgery for primary chronic RRD at KKESH during 2014–2018. Preoperatively, all cases had a history of decreased vision for 3 months or greater, established PVR-related RRD on preoperative fundus examination, intraretinal cyst, and watershed marks. Those who had a previous history of retinal surgery, combined pathology such as tractional retinal detachment and vitreous hemorrhage, and a follow-up of < 12 months were excluded. All patients gave an informed consent for the procedure preoperatively. This study was approved by the Institutional Review Board of KKESH.

Data were collected from the medical records on the baseline characteristics such as age, gender, preoperative best-corrected visual acuity (BCVA), lens status, macular involvement, PVR grade and location, preexisting break, and the number and location of the breaks); and intraoperative factors such as type of surgery (PPV or SB). Postoperative data were collected on the need for additional surgery and on anatomic and visual outcomes. BCVA using Snellen chart, intraocular pressure (IOP), lens status, epiretinal membrane formation, extraocular movement defect, PVR grade and location, residual subretinal fluid, and choroidal detachment were evaluated at 1 month, 3 months, 6 months, and 12 months. Our outcomes were as follows: (1) Anatomic success which was defined as attachment of the retina at 12 months after primary surgery without any additional surgeries during that interval and (2) Change in logMAR BCVA at 12 months from baseline.

Surgical procedure

Scleral buckling was performed with conventional and chandelier-assisted techniques as follows: After a 360° limbal peritomy and isolation of the four rectus muscles, retinal breaks were localized (if possible) and marking was performed and measured from the limbus to decide the placement of the buckle element (the type of the buckle was based on the nature of the break). Cryotherapy was used to induce a chorioretinal scar when the retinal break had been localized before tightening the buckle element. Subretinal fluid drainage and intraocular tamponade after subretinal fluid drainage were performed in some cases with intraocular gas or air injection.

Primary vitrectomy was performed using a 23G three-port PPV. Vitrectomy was performed, and endo laser was used to create chorioretinal adhesions. Liquid perfluorocarbon was used to flatten the retina during the procedure. Subretinal fluid was drained through existing breaks. Either gas or silicone oil was used for the intraocular tamponade.

Statistical analysis

Data were entered in a Microsoft Access (Microsoft Corporation, Redmond, WA) database and analyzed using the STATA 16.0 (Stata Corp LLC, College Station, TX, USA). The continuous variables were expressed as mean, standard deviation, median and interquartile range and categorical variables as frequencies and percentages. Cox-regression analysis was performed to identify the factors associated with retinal detachment. In addition, a linear regression analysis was performed to assess if the surgery type was associated with change in BCVA from baseline to 12 months, adjusting for different prognostic factors. Adjusted R2 was calculated to assess the predictive power of each of the selected variables. Multicollinearity was assessed using the variance inflation factor. Postestimation, the Breusch-Pagan/Cook-Weisberg test for heteroscedasticity was used to determine if the variance of the residual was constant. We determined if the residuals were normally distributed. We used Stata's postestimation margins command to predict the mean change in BCVA. For all the analysis, a P < 0.05 was considered statistically significant.


   Results Top


We reviewed medical records of a total of 1360 patients who underwent surgical repair for retinal detachment during 2014–2018. Of these 78 and 66 patients had undergone SB surgery and PPV for chronic RRD, respectively. Ten patients in the SB surgery group and two in the PPV group were excluded due to incomplete follow-up. Thus, a total of 68 patients in the SB surgery group and 64 in PPV were included. Preoperatively, patients in the SB surgery group were significantly younger (P < 0.001), and more likely to have a clear lens (P < 0.001), and PVR grade C (P < 0.008) than those in the PPV group [Table 1]. Forty-seven cases in PPV and none in the SB surgery group had silicone oil.
Table 1: Characteristics of patients with chronic rhegmatogenous retinal detachment who underwent scleral buckling or pars plana vitrectomy

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SB surgery had a consistently higher rate of single surgery success compared to PPV at 1 month and 3, 9, and 12 months [Figure 1].
Figure 1: Anatomical success rates of single surgery at 1 month and 3, 9, and 12 months in the two groups

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[Table 2] shows a comparison of risk of retinal detachment across different groups. Lens status and the type of surgery were the only variables that were marginally associated with risk of retinal detachment in the multivariable cox-regression analysis. Patients who had cataract were more likely to develop retinal detachment over 12 months than those who had a clear lens (heart rates [HR] 2.12 95% confidence interval [CI], 0.99–4.50 P = 0.05). Patients who underwent PPV were more likely to develop retinal detachment over 12 months than those who underwent SB surgery (HR 2.11, 95% CI, 0.95–4.64 P = 0.065).
Table 2: Anatomic outcome of scleral buckling surgery versus pars plana vitrectomy in patients with chronic rhegmatogenous retinal detachment

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[Table 3] and [Figure 2] show the values for change in visual acuity from baseline to 12 months. The mean change in best-corrected log MAR VA was −0.15 in the PPV group compared with −0.12 in SB group. However, the difference in two means (−0.03) was not statistically significant (P = 0.754). [Figure 3] shows a scatter plot of the relationship between change in BCVA at 12 months and the BCVA at presentation. Significant vision improvement occurred in each of the two treatment groups, but there were no significant within-group differences.
Table 3: Summary statics for change in visual acuity from baseline to 12 months, across groups

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Figure 2: Box plot showing the median (bold horizontal line), interquartile range (box) and total range (whiskers) of values of best-corrected visual acuity

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Figure 3: Scatter plot of the relationship between change in best-corrected visual acuity at 12 months and best-corrected visual acuity at presentation, by treatment group

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A multiple linear regression analysis did not reveal a significant association between the surgery type and change in visual acuity (beta coefficient, 0.002; 95% CI, −0.184, 0.189 for specific bread volume; P = 0.979) [Table 4]. The analysis revealed that BCVA at presentation had the strongest negative association with change in BCVA [β-0.34, 95% CI:-0.50, −0.19; P < 0.001 [Table 3] and [Figure 4]. In addition, compared with their reference groups, patients with detached retina (β = 0.37, 95% CI: 0.20, 0.54, P < 0.001) and those with PVR grade C at baseline (β = 0.18, 95% CI: 0.01, 0.34, P = 0.037) had worsening in BCVA. The multivariable model, comprising treatment group, age at surgery, gender, eye involved, lens status, macular involvement, PVR grade, BCVA at baseline and retina status at 1 year explained 32.8% variance in BCVA change (adjusted R2 = 0.3281). Of these variables, much of the variance (25.6%) was contributed by two factors-BCVA at baseline and retina status at 1 year (adjusted R2 = 0.2556). We used Stata's postestimation margins command to predict adjusted mean change in BCVA, as shown in [Figure 4].
Table 4: Linear regression analysis of factors associated with change in logMAR visual acuity from baseline to 12 months (n=120)

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Figure 4: Multiple linear regression model-based plot of predicted change in best-corrected visual acuity for different levels of best-corrected visual acuity at presentation, by treatment group

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Postoperatively, 1 (1.5%) patient in the SB surgery group and 4 (6.3%) patients in the PPV group developed iatrogenic breaks. Further, uncontrolled elevated IOP was observed in 9 (14.1%) patients in the PPV group compared with none in the SB group. One patient complained of diplopia in the SB group. However, the angle of deviation was not clinically significant, and no intervention was needed. A significantly higher proportion of patients in the PPV group compared with those in the SB surgery group required secondary surgery (39.1% vs. 22.1%; P = 0.034).


   Discussion Top


This study compared the anatomical and visual outcomes of SB surgery with PPV as a primary surgical technique in patients with chronic RRD. We found that at 12 months, attachment rate with single surgery was higher for those undergoing SB surgery than for those undergoing PPV (74.1% vs. 59.7%). Visual improvement in the PPV and SB surgery groups was similar.

To date, only a few studies have compared the effectiveness of the two procedures in patients with chronic RRD. The comparison of our findings with those of previous studies is difficult for a variety of reasons, including baseline differences in case selection (based on lens status, location of the break, and age of the patients), vitreous body status (presence or absence of PVD), surgeons' expertise, and the length of the follow-up.[4],[8],[9]

In our study, SB surgery was associated with a consistently higher rate of single surgery success compared to PPV at 1 month and 3, 9, and 12 months. These outcomes are comparable to previous reports,[6],[9] although in our study, SB group had a significantly higher proportion of complicated chronic RRD (41.2% had grade C PVR; all had subretinal bands) than the PPV group (23.4% had grade C PVR; only one case had subretinal bands). Our study showed that a higher proportion of patients required secondary surgery in the PPV group compared to the SB group. This finding indicates that SB is likely to be a better choice for more complicated chronic RRD repair with subretinal band as compared to PPV alone.[2],[9]

Our analysis showed that vision improvement in the PPV and SB surgery group remained almost the same. Preoperative visual acuity is considered a strong predictor of the final visual outcome after successful retinal reattachment.[10] This was also the case in our study. Despite achieving anatomical success, it is well-known that irreversible damage to photoreceptors and disruption of normal retinal morphology are the most important factors in determining postoperative visual acuity.[8],[10]

In the current study, those with macula-off had better vision improvement than those with macula-on, but this difference reached only marginal significance. This finding is unexpected. As this was an observational study, so it is possible that some unmeasured confounding remains.

Diplopia has been reported after SB and PPV.[11] In our study, only one patient who underwent SB surgery had diplopia which could have been due to misalignment of retinal receptors on macular reattachment, suture sites, sensory disruption, or preoperative heterophoria.

The strength of this study is the ability to study a relatively rare condition and adjust for important confounding variables. To our knowledge, this is one of small number of studies[6],[8] looking at the anatomical and visual outcomes of SB surgery and PPV specifically for chronic RRD with varying PVR complexity.

There are some limitations to the current study including its observational nature. Multiple surgeons performed these surgeries which may have resulted in variation in the outcomes according to surgeon experience. In addition, the combined procedure of SB with PPV for chronic RRD repair was not addressed in this study. Selection bias was another limitation of this study as it included a variety of complex cases of chronic RRD and differing lens status and it is unclear how the cases were assigned to specific surgical groups given the retrospective nature of the study. An adequately sized multicenter randomized trial of chronic RRD surgery repair techniques is needed to provide evidence-based treatment recommendations.


   Conclusion Top


While both surgical procedures offered comparable effect in terms of vision improvement, SB surgery had some advantage over PPV alone as the primary surgical procedure in complex chronic RRD cases. SB surgery was associated with a consistently higher anatomical success rate compared to PPV and can be the preferred procedure for phakic chronic RRD with varying complexity PVR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Li YM, Fang W, Jin XH, Li JK, Zhai J, Feng LG. Risk factors related to chronic rhegmatogenous retinal detachment. Int J Ophthalmol 2012;5:92-6.  Back to cited text no. 1
    
2.
Yao Y, Jiang L, Wang ZJ, Zhang MN. Scleral buckling procedures for longstanding or chronic rhegmatogenous retinal detachment with subretinal proliferation. Ophthalmology 2006;113:821-5.  Back to cited text no. 2
    
3.
Kobashi H, Takano M, Yanagita T, Shiratani T, Wang G, Hoshi K, et al. Scleral buckling and pars plana vitrectomy for rhegmatogenous retinal detachment: An analysis of 542 eyes. Curr Eye Res 2014;39:204-11.  Back to cited text no. 3
    
4.
Park SW, Lee JJ, Lee JE. Scleral buckling in the management of rhegmatogenous retinal detachment: Patient selection and perspectives. Clin Ophthalmol 2018;12:1605-15.  Back to cited text no. 4
    
5.
Heimann H, Bartz-Schmidt KU, Bornfeld N, Weiss C, Hilgers RD, Foerster MH, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: A prospective randomized multicenter clinical study. Ophthalmology 2007;114:2142-54.  Back to cited text no. 5
    
6.
Lai FH, Lo EC, Chan VC, Brelen M, Lo WL, Young AL. Combined pars plana vitrectomy-scleral buckle versus pars plana vitrectomy for proliferative vitreoretinopathy. Int Ophthalmol 2016;36:217-24.  Back to cited text no. 6
    
7.
Oshima Y, Yamanishi S, Sawa M, Motokura M, Harino S, Emi K. Two-year follow-up study comparing primary vitrectomy with scleral buckling for macula-off rhegmatogenous retinal detachment. Jpn J Ophthalmol 2000;44:538-49.  Back to cited text no. 7
    
8.
Wong CW, Yeo IY, Loh BK, Wong EY, Wong DW, Ong SG, et al. Scleral buckling versus vitrectomy in the management of macula-off primary rhegmatogenous retinal detachment: A comparison of visual outcomes. Retina 2015;35:2552-7.  Back to cited text no. 8
    
9.
Ahmadieh H, Moradian S, Faghihi H, Parvaresh MM, Ghanbari H, Mehryar M, 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.  Back to cited text no. 9
    
10.
Friberg TR, Eller AW. Prediction of visual recovery after scleral buckling of macula-off retinal detachments. Am J Ophthalmol 1992;114:715-22.  Back to cited text no. 10
    
11.
Wright LA, Cleary M, Barrie T, Hammer HM. Motility and binocularity outcomes in vitrectomy versus scleral buckling in retinal detachment surgery. Graefes Arch Clin Exp Ophthalmol 1999;237:1028-32.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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