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Approximately 30% to 40% of rhegmatogenous retinal de- buckling is a standard surgical method to manage RD after
tachments (RDs) occur after cataract surgery.1,2 Scleral cataract surgery. Nevertheless, the outcomes of scleral
buckling in aphakic and pseudophakic eyes generally are
Originally received: September 7, 2004.
Accepted: February 11, 2005. Manuscript no. 2004-83. Presented at: American Academy of Ophthalmology Annual Meeting,
1
Ophthalmic Research Center, Labbafinejad Medical Center, Tehran, Iran. November, 2003; Anaheim, California.
2
Farabi Eye Hospital, Tehran, Iran. Supported by the National Research Center of Medical Sciences, Tehran,
3
Rasoul Akram Hospital, Tehran, Iran. Iran, and the Ophthalmic Research Center of Shaheed Beheshti University
4
of Medical Sciences, Tehran, Iran.
Feiz Hospital, Esfahan, Iran.
5
None of the authors have a financial interest in the subject matter of the article.
Khalili Eye Hospital, Shiraz, Iran.
6
Correspondence to Hamid Ahmadieh, MD, Ophthalmic Research Center,
Nikoukari Hospital, Tabriz, Iran. Labbafinejad Medical Center, Pasdaran Ave. Boostan 9 St., Tehran 16666,
7
Amiralmomenin Hospital, Rasht, Iran. Iran. E-mail: hahmadieh@hotmail.com.
8
Emam Reza Hospital, Mashad, Iran. *For Study Group membership, see “Appendix.”
© 2005 by the American Academy of Ophthalmology ISSN 0161-6420/05/$–see front matter 1421.e1
Published by Elsevier Inc. doi:10.1016/j.ophtha.2005.02.018
Ophthalmology Volume 112, Number 8, August 2005
less favorable than in phakic eyes.3,4 The range of anatomic Exclusion Criteria
success varies from 61.5% to 80% in cases of pseudophakic
Patients with history of RD surgery in the affected eye, ocular
and aphakic RD managed by scleral buckling.3–5 Undiag- trauma, diabetic retinopathy, glaucoma, uveitis, macular hole, wet
nosed retinal breaks are an important cause of failure in type age-related macular degeneration and macular geographic
these cases resulting from the smaller size and anterior atrophy, giant retinal tear, PVR greater than grade B, 1-eyed
location of retinal breaks as well as incomplete fundus view patients, patients younger than 15 years of age, patients with dense
because of anterior or posterior capsular fibrosis, cortical vitreous hemorrhage obscuring fundus view, and those with a
remnants, poor pupillary dilation, vitreous opacities, and localized detachment extending less than 1 quadrant with a definite
optical aberrations secondary to the intraocular lens (IOL) retinal break were excluded from the study.
itself.6 In addition to unseen retinal breaks, proliferative After recording data in information sheets and applying the
inclusion criteria, patients were randomly allocated into one of the
vitreoretinopathy (PVR) has been shown to occur more
following treatment groups: (1) scleral buckling or (2) vitrectomy
frequently in pseudophakic and aphakic RD.3,7 without an encircling band or any buckle. Simple random assign-
Recent advances in vitrectomy technique have encour- ment was performed using SPSS software (version 10.0).23 All
aged vitreoretinal surgeons to expand the role of primary patients were operated either by an attending vitreoretinal surgeon
pars plana vitrectomy in the management of uncomplicated or by vitreoretinal fellows with at least 6 months of training.
RDs.8 –14 Primary vitrectomy especially has been consid- The clinical trial was approved by the Review Board/ Ethics
ered as first-line surgical treatment in cases of pseudophakic Committee of the Ophthalmic Research Center.
and aphakic RD.14 –20 The rationale for such an approach
includes the ability to remove retained lens material, vitre- Surgical Technique
ous opacities, and retinal pigment epithelial cells, while
allowing controlled drainage of subretinal fluid. Other po- Scleral Buckling. Conventional techniques of scleral buckling
tential advantages of primary vitrectomy in these cases may were used for the buckle group: after a 360° limbal peritomy and
passing traction sutures under the rectus muscles, retinal breaks
be the ability to visualize small retinal breaks with or were localized (if possible) and sutures were placed in the sclera
without simultaneous scleral depression and appropriate such that the buckle indented the site of the break and 1 clock hour
application of retinopexy. The absence of risk of cataract on either side, 4 mm posterior and 2 to 3 mm anterior to it. If
formation is another reason for surgeons’ tendency to per- fishmouth phenomenon was a possibility because of the type of the
form primary vitrectomy in aphakic and pseudophakic eyes. break or if circumferential scleral buckling was not feasible, a
Recently, there have been retrospective and prospective meridional sponge (no. 505 or 507) was placed in addition to an
case series showing promising results of primary vitrectomy encircling band no. 240. There were cases in which no definite
in the management of pseudophakic and aphakic RD.15–20 retinal break could be found, either before or during the operation.
Most of these studies however, suffer from selection bias, In these cases, if the RD was incomplete, a circumferential buckle
(silicone tire no. 276) was used in the area of RD, but if there was
and the necessity of conducting a controlled randomized total RD, the same buckle was used for 360°. In all cases, an
trial has been emphasized by many authors.13–15,18,19,21,22 encircling band no. 240 was also placed to produce a moderate
Our study was designed as a multicenter controlled clin- buckle height. Cryotherapy was used to induce a chorioretinal scar
ical trial to compare the anatomic and visual outcomes of when the retinal break had been localized and scleral sutures had
scleral buckling with primary vitrectomy alone in pseu- been placed. Cryospots were applied at the edges of the breaks and
dophakic and aphakic RD. Herein, we report the primary not on their beds. Cryotherapy was not used in cases of unseen
outcomes of a single operation. These are the results of a retinal breaks; in such cases, 360° laser treatment was applied on
6-month follow-up study. the encircling buckle within 1 week after surgery.
For subretinal fluid (SRF) drainage, a 2-mm sclerotomy was
created approximately 1 clock hour adjacent to horizontal recti
muscles or beneath the vertical recti muscles, in loci in which the
greatest amount of SRF existed. After cauterization or diathermy
Patients and Methods of the choroidal bed at the sclerotomy site, SRF was drained and
the sclerotomy was closed with 8-0 silk suture. If severe ocular
Clinical Examination hypotony occurred after SRF drainage, saline solution was injected
intracamerally (in aphakic eyes) or intravitreally (in pseudophakic
All patients underwent an interview for comprehensive history, eyes). In cases of shallow RD or little SRF, the stage of subretinal
including onset of visual symptoms resulting from RD, date of fluid drainage was omitted.
cataract surgery, history of previous ocular operations, other ocular Primary Vitrectomy. Three-port pars plana vitrectomy was
disorders including glaucoma and diabetic retinopathy, ocular used for patients in the vitrectomy group. Sclerotomies were
trauma, and history of RD in the fellow eye. Clinical examination created 3 mm from the limbus, and a standard pars plana deep
included determination of best-corrected visual acuity (BCVA); vitrectomy was performed, avoiding debulking of the vitreous
relative afferent pupillary defect in the affected eye and refraction base. All vitreous attachments to the edge of retinal breaks were
of the fellow eye; slit-lamp examination, including assessment of removed, as were attachments to the IOL, iris, or wound. Subreti-
the anterior segment, type, and position of IOL and integrity of the nal fluid was drained using perfluorocarbon liquid. Perfluorocar-
posterior capsule; and intraocular pressure (IOP) measurement. bon liquid was injected on the posterior pole through a 20-gauge
Funduscopic examination was performed to evaluate the extent of blunt cannula as a single large bubble. This resulted in subretinal
RD, the presence of any predisposing pathologic features in the fluid egressing from the preexisting peripheral retinal break(s).
peripheral retina, PVR grading, signs of myopic degeneration and Endolaser was used to create chorioretinal adhesions. If retinal
to find retinal breaks and to determine their location, type, and breaks could not be found, laser was used to create 2 to 3 rows of
number. Findings were recorded in relevant information sheets. burns posterior to the entire vitreous base. Finally, fluid–air ex-
1421.e2
Ahmadieh et al 䡠 Scleral Buckling versus Primary Vitrectomy
1421.e3
Ophthalmology Volume 112, Number 8, August 2005
Follow-up
Period (mos) Buckle Group Vitrectomy Group P Value
logMAR (BCVA; mean ⫾ [SD]) 1 1.25 (0.67) 1.24 (0.68) 0.92
2 1.08 (.65) 1.16 (0.70) 0.47
4 0.98 (.65) 1.01 (0.63) 0.84
6 0.96 (.68) 0.96 (.62) 1
Retinal reattachment (no. [%]) 1 104 (82.5) 75 (75.7) 0.26
2 93 (73.8) 67 (67.7) 0.77
4 91 (72.2) 62 (62.6) 0.32
6 86 (68.2) 62 (62.6) 0.24
BCVA ⫽ best-corrected visual acuity; logMAR ⫽ logarithm of the minimum angle of resolution; SD ⫽ standard
deviation.
ing by myopic degeneration did not appreciably change the odds visual categories (20/40 or better, 20/200 to 20/50, less than
ratio. Nevertheless, in comparing the cases of retinal reattachment 20/200) is shown in Figure 4. The difference between the 2 groups
with cases of redetached retina after 6 months, myopic degenera- was not statistically significant (P ⫽ 0.95).
tion was found to have a statistically significant effect on the The BCVA (logarithm of the minimum angle of resolution
anatomic outcome in both groups (P ⫽ 0.04). The anatomic [logMAR]) at the 1-, 2-, 4-, and 6-month postoperative follow-up
success rate in eyes with vitreous incarceration at the 6-month examinations were 1.25⫾0.67, 1.08⫾0.65, 0.98⫾0.65, and
follow-up examination in the buckle and vitrectomy groups were 0.96⫾0.68 in the buckle group and 1.24⫾0.68, 1.16⫾0.70,
57.1% and 66.7%, respectively, which did not show any statisti- 1.01⫾0.63, and 0.96⫾0.62 in the vitrectomy group, respectively.
cally significant difference (Fig 3). There was no statistically significant difference between the 2
In a logistic regression model, none of the preoperative vari- groups (Table 2). Based on a general linear model (2-way repeated
ables (patient age, preoperative visual acuity, family history of RD, measure), time had a significant effect on improving visual acuity.
RD extension, vitreous incarceration into cataract wound, history Visual acuity significantly improved after surgery compared with
of secondary IOL implantation) nor type of RD surgery (scleral preoperative visual acuity in both groups (P⬍0.0001). This im-
buckling vs. primary vitrectomy) had significant effect on ana- provement continued until 2 months after surgery in both groups
tomic success. (P ⫽ 0.007), but there was no significant improvement after 4
months (Figs 5, 6).
Multiple regression analysis showed that preoperative visual
Visual Results acuity was the only variable with a significant effect on postoper-
Of 86 eyes with reattached retinas after 6 months, 11 eyes (12.8%) ative visual acuity. The final model was: 0.345⫹0.277⫻logMAR
gained visual acuity of 20/40 or better in the buckle group. In the of preoperative BCVA, indicating that being in either surgical
vitrectomy group, 7 of 62 eyes with reattached retinas (11.3%) treatment group had no effect on postoperative visual acuity.
gained this level of visual acuity after 6 months (P ⫽ 0.78). Of 86
eyes, 57 eyes (66.3%) and 40 of 62 eyes (64.5%) achieved visual Complications
acuity of 20/200 or better in the buckle and vitrectomy groups,
respectively. Again, there was no statistically significant difference The rates of macular pucker at the 1-, 2-, 4-, and 6-month
between the 2 groups (P ⫽ 0.82). The distribution of visual acuity postoperative examinations were 15%, 15.9%, 22.2%, and
6 months after surgery in each treatment group according to 3 22.2% in the buckle group, respectively, and were 12.1%,
%
30
25
Retinal redetachment rate
20
Buckle
15
Vitrectomy
10
0
1st month 2nd month 4th month 6th month
Figure 1. Rate of retinal redetachment at follow-up examinations in each treatment group.
1421.e4
Ahmadieh et al 䡠 Scleral Buckling versus Primary Vitrectomy
%
92.5 94.6 Buckle
13.1%, 14.1%, and 22.2%, respectively, in the vitrectomy aphakic RD. The 2 treatment groups were matched for most
group. The rates of clinical CME were 11.1%, 9.5%, 8.7%, and of the preoperative characteristics (sex, interval of cataract
6.3% in the buckle group, respectively, and were 16.2%, 13.1%, surgery and RD, history of RD in the fellow eye, history of
9.1%, and 9.1%, respectively, in the vitrectomy group. The
rates of postoperative IOP more than 20 mmHg with medica-
neodymium:yttrium–aluminum– garnet laser capsulotomy,
tions were 11.9%, 8.7%, 7.1%, and 6.3% in the buckle group, macular status, IOL position, type of cataract surgery, IOP,
respectively, and were 10.1%, 9.1%, 7.1%, and 6.1%, respec- vitreous hemorrhage, relative afferent pupillary defect, ex-
tively, in the vitrectomy group. The rates of early postoperative traocular muscle dysfunction, and interval of RD symptoms
IOP rise (IOPⱖ20 mmHg) within 1 week after RD surgery in to RD surgery). There were, however, statistically signifi-
the buckle and vitrectomy groups were 24.6% and 26.3%, cant differences in some of the preoperative characteristics
respectively. The rates of choroidal detachment were 6.3%, in the 2 treatment groups. These variables included age,
3.2%, 1.6%, and 0%, respectively, in the buckle group and 2.0%
at month 1 and 0% at month 2 and thereafter, in the vitrectomy
BCVA (logMAR), family history of RD, RD extension,
group. The rates of extraocular muscle dysfunction in the vitreous incarceration into the cataract wound, and rate of
buckle and vitrectomy groups at 6 months were 4.0% and 0%, secondary IOL implantation. There was a borderline differ-
respectively. None of these complications showed any statisti- ence between the 2 groups related to the prevalence of
cally significant difference between the 2 groups (Table 3). myopic degeneration. The 2 groups were adjusted for these
variables.
There are no studies demonstrating a consistent relation
Discussion between patients’ age and anatomic success after RD sur-
gery. Most patients in both groups were cases with a history
We conducted a randomized clinical trial to compare the of age-related (senile) cataract surgery. The statistically
anatomic and visual outcomes of the 2 techniques (conven- significant difference between the mean age of patients in
tional scleral buckling vs. primary vitrectomy without the 2 treatment groups did not seem to be of clinical sig-
scleral buckle) in the management of pseudophakic and nificance. In addition, after adjusting for preoperative pa-
%
90
Anatomic success rate
80
70
60
50 Buckle
40 Vitrectomy
30
20
10
0
with vitreous incarceration without vitreous
incarceration
Figure 3. Comparison of anatomic success in eyes with and without vitreous incarceration in each treatment group.
1421.e5
Ophthalmology Volume 112, Number 8, August 2005
2.5
Best corrected visual acuity
1.5
Buckle
1 vitrectomy
0.5
0
preop VA postop VA
Figure 5. Preoperative and 6 month postoperative best-corrected visual acuity (VA) in each treatment group according to logarithm of the minimum
angle of resolution.
1421.e6
Ahmadieh et al 䡠 Scleral Buckling versus Primary Vitrectomy
2.5
0.5
0
Before 1st month 2nd month 4th month 6th month
operation
Figure 6. Improvement of best-corrected visual acuity (logarithm of the minimum angle of resolution) after retinal detachment surgery over time in each
treatment group.
acuity was the most important variable. In our study, pre- vision after RD surgery. Duration of macular involvement is
operative visual acuity was also the single factor having the one of the most important variables associated with return
highest correlation with visual outcome. There was no sta- of central vision.28 There is a significant decrease in visual
tistically significant difference between the 2 treatment recovery with macula-off detachments lasting longer than 1
groups regarding visual results. In other words, being in week.29 The duration of RD with macular involvement in
either surgical technique group did not have a significant our series was longer than in other reports. Higher patient
effect on the visual outcome. This shows that preoperative age is associated with a trend toward reduced postoperative
visual acuity is the most influential factor on final vision not visual acuity.24,28 –30 Most of our patients were older, with
only in scleral buckling, but also with newer methods of RD a median age of 64 years. The extent of RD also has been
surgery. Improvement in postoperative visual acuity was shown to have an inverse relationship with anatomic and
observed during the follow-up period, especially during the visual outcomes.24,28,30 –32 Most RDs in both treatment
first 4 months after surgery. groups in our study were total or nearly total. Only 2.4% of
Macular involvement is an important factor influencing eyes in the scleral buckling group and 2.1% of eyes in the
Follow-up
Period (mos) Buckle Group Vitrectomy Group *P Value
EOM dysfunction (no. [%]) 1 4 (3.2) 0 (0.0) 0.12
2 5 (4.0) 1 (1.0) 0.22
4 5 (4.0) 0 (0.0) 0.07
6 5 (4.0) 0 (0.0) 0.07
Choroidal detachment (no. [%]) 1 8 (6.3) 2 (2.0) 0.10
2 4 (3.2) 0 (0.0) 0.13
4 2 (1.6) 0 (0.0) 0.50
6 0 (0.0) 0 (0.0) —
Clinical CME (no. [%]) 1 14 (11.1) 16 (16.2) 0.41
2 12 (9.5) 13 (13.1) 0.51
4 11 (8.7) 9 (9.1) 1.0
6 8 (6.3) 9 (9.1) 0.43
Macular pucker (no. [%]) 1 19 (15.0) 12 (12.1) 0.40
2 20 (15.9) 13 (13.1) 0.69
4 28 (22.2) 14 (14.1) 0.13
6 28 (22.2) 22 (22.2) 1.0
Postoperative IOP ⬎20 mmHg with medications 1 15 (11.9) 10 (10.1) 0.66
(no. [%])
2 11 (8.7) 9 (9.1) 1.0
4 9 (7.1) 7 (7.1) 1.0
6 8 (6.3) 6 (6.1) 1.0
Anisometropia at sixth month (mean ⫾ [SD]) Sphere 1.92 (2.18) 1.78 (2.2) 0.76
Cylinder 0.44 (0.71) 0.26 (0.49) 0.20
CME ⫽ cystoid macular edema; EOM ⫽ extraocular mucle; IOP ⫽ intraocular pressure; SD ⫽ standard deviation.
*Fisher exact probability.
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Ophthalmology Volume 112, Number 8, August 2005
vitrectomy group were macula-on. Proliferative vitreoreti- a variety of surgical techniques as substitutes for scleral
nopathy grade B already has been identified to be a risk buckling to repair uncomplicated RD, Wilkinson21 wrote an
factor for anatomic failure.33 All patients in our series editorial entitled “Wanted: Optimal Data Regarding Surgery
showed the signs of PVR grade B before surgery. Training for Retinal Detachment.” He emphasized the importance of
vitreoretinal fellows in educational centers performed some discovering the optimal method of repairing RDs and men-
of the operations. This also may have had a negative effect tioned that a large, prospective, randomized trial would be
on the results. required to answer this question. He assumed, however, that
Macular pucker is a common finding after RD surgery. It no single technique would be considered optimal for all
has been reported in 2% to 17% of detachment cases un- RDs. Our study provides adequate information in this re-
dergoing scleral buckling.34 Extensive RD and involvement gard.
of the macula have been noted to be associated with devel- We found that primary vitrectomy without scleral buckle
opment of macular pucker.34 Macular pucker also has been was not more effective than conventional scleral buckling in
reported as a frequent complication of primary vitrectomy the management of uncomplicated RD in eyes with a history
for pseudophakic and aphakic RD.19 We observed a high of cataract extraction. Based on our results, we believe that
rate of this complication in our study, and there was no at present, no single surgical technique can be considered as
statistically significant difference between the 2 treatment optimal and routine for all cases of pseudophakic and apha-
groups. The incidence of this complication increased grad- kic RD. It is noteworthy to consider some of the following
ually during the 6-month follow-up period. factors in selecting each of these options in this group of
Choroidal detachment has been reported as one of the patients: the costs of these operations, experience and ca-
most common complications of scleral buckling for repair pabilities of vitreoretinal surgeons, and the availability of
of pseudophakic and aphakic RD.3,5 In the series reported appropriate instrumentation. The possible effect of an en-
by Yoshida et al,5 it was the most common postoperative circling band on the rate of retinal reattachment in cases of
complication and was observed in 21.5% of the cases. In our primary vitrectomy remains a question that needs to be
series, this complication was more frequent in the scleral answered in another controlled study.
buckling group compared with the vitrectomy group, but the Acknowledgments. The PARD study group thanks Shahin
difference was not statistically significant. Yazdani, MD, Arash Anissian, MD, Zahra Rabbanikhah, MD,
Cystoid macular edema is another frequent complication Nasrin Rafati, MD, Mr Ali A. Aghdaee, Ms Maryam Ghazaee, Ms
after retinal surgery.34 It is more prevalent in aphakic than Leila Azadvari, and Mr Mohammad R. Farrokhian for their assis-
tance during the course of the study.
in phakic eyes. We evaluated the incidence of clinical CME
in our patients. There was no significant difference between
the 2 treatment groups regarding this complication. References
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Ophthalmology Volume 112, Number 8, August 2005
Table 1. Basic Characteristics of Patients in the 2 Treatment Groups at the Beginning of Study
AC IOL ⫽ anterior chamber intraocular lens; BCVA ⫽ best-corrected visual acuity; ECCE ⫽ extracapsular cataract extraction; ICCE ⫽ intracapsular
cataract extraction; IOL ⫽ intraocular lens; IOP ⫽ intraocular pressure; LogMAR ⫽ logarithm of minimum angle of resolution; PCIOL ⫽ posterior
chamber intraocular lens; PE ⫽ phacoemulsification; RAPD ⫽ relative afferent pupillary defect; RD ⫽ retinal detachment.
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