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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 16  |  Issue : 2  |  Page : 84-88

Pars plana vitrectomy with endolaser barrage 360° versus pars plana vitrectomy with scleral buckle for treatment of primary retinal detachment with inferior breaks


Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission18-Jun-2014
Date of Acceptance08-Nov-2014
Date of Web Publication28-Oct-2015

Correspondence Address:
Hesham A Enany
Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-9173.165059

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  Abstract 

Purpose
The aim of the study was to compare intraoperative and postoperative complications and the recurrence rate after pars plana vitrectomy (PPV) with endolaser barrage 360° compared with PPV with scleral buckle (SB) for primary retinal detachment (RD) with inferior breaks.
Patients and methods
This prospective randomized study evaluated postoperative results in 40 patients with primary RD with inferior breaks. They presented with primary RD with inferior breaks and were divided into two groups, each group including 20 patients; the first group was treated by means of PPV with endolaser barrage 360°, and the second group was treated by means of PPV with SB. Intraoperative and postoperative complications and recurrence rate were recorded. Follow-up was carried out for 3 months.
Results
The mean age of patients in the first group was 56.2 years, whereas the mean age of patients in the second group was 55.3 years. Recurrent RD occurred in 10% of cases in the first group and in 5% of cases in the second group. Success rate was 90% (18 of 20 cases) in the first group and 95% (19 of 20 cases) in the second group.
Conclusion
Acceptable success rates can be achieved using PPV with endolaser barrage 360° to treat RD with inferior breaks. Supplementary SB is unnecessary to support the inferior retina as endolaser barrage with silicon oil and good positioning achieve tempo nade of the inferior breaks satisfactorily. Further, PPV with endolaser barrage 360° has fewer intraoperative and postoperative complications compared with PPV with SB.

Keywords: endolaser barrage, inferior breaks, pars plana vitreotomy


How to cite this article:
Al-Aswad MA, Enany HA. Pars plana vitrectomy with endolaser barrage 360° versus pars plana vitrectomy with scleral buckle for treatment of primary retinal detachment with inferior breaks . Delta J Ophthalmol 2015;16:84-8

How to cite this URL:
Al-Aswad MA, Enany HA. Pars plana vitrectomy with endolaser barrage 360° versus pars plana vitrectomy with scleral buckle for treatment of primary retinal detachment with inferior breaks . Delta J Ophthalmol [serial online] 2015 [cited 2017 Dec 12];16:84-8. Available from: http://www.djo.eg.net/text.asp?2015/16/2/84/165059


  Introduction Top


Successful retinal attachment surgery requires effective treatment for breaks and relief of vitreoretinal traction. Scleral buckle (SB) is the most well-established technique and has the longest published follow-up data [1] .

However, pars plana vitrectomy (PPV) has grown in popularity as the first-line procedure for primary retinal detachment (RD), especially in pseudophakic patients. SB has high success rates for many primary RDs, except for cases with very posterior breaks and cases in which placing the buckling elements is technically too difficult, such as eyes with thin sclera, prior strabismus surgery, glaucoma drainage devices, etc. Additional relative contraindications to SB alone (without PPV) include giant retinal tear, proliferative vitreoretinopathy (PVR) grade C, and significant vitreous opacity or hemorrhage [2] .

Conventional scleral buckling is a safe and effective option for treating uncomplicated rhegmatogenous retinal detachment. However, it is associated with certain complications. Subretinal bleeding is the most common intraoperative complication. Raised intraocular pressure is the most common early postoperative complication, followed by choroidal detachment [3] .

The mechanisms of recurrent RD are hypothesized to be opening of pre-existing breaks, posterior migration of occult RD, formation of new retinal breaks, and traction on the vitreous base. Laser barrage 360° reduced the incidence of recurrent RD after silicone oil removal from 26 to 14% [4] .

The success rate of management of giant retinal tears with vitrectomy, internal tamponade, and peripheral 360° photocoagulation of the retina without SB is high. Photocoagulation of the peripheral retina over 360° appears to decrease the risk for secondary peripheral retinal tears [5] .

When patients with inferior retinal breaks require a vitrectomy it is routinely carried out in combination with SB in order to support the inferior retina, thus avoiding difficult posturing. The procedure is technically demanding, has an increased risk for choroidal hemorrhage [6] , requires longer operating time [7] , and has all the associated complications of SB: that is, exposure, refractive changes, diplopia, possible decreased retinal blood flow, and risk of anterior segment ischemia [8] .

This study was designed to evaluate PPV with endolaser barrage 360° versus PPV with SB for primary RD with inferior breaks as regards intraoperative and postoperative complications and recurrence rate.


  Patients and methods Top


The study was carried out on patients attending the outpatient clinic of Zagazig University from October 2012 to October 2013.

Forty eyes of 40 patients who had primary RD with inferior breaks were divided into two groups, each group comprising 20 patients. The first group was selected for PPV with endolaser barrage 360° and the second group was selected for PPV with SB.

Each case underwent a complete ophthalmic examination, evaluation of best-corrected visual acuity, slit lamp biomicroscopy, and indirect ophthalmoscopy.

Preoperative determination of clinical features of the RD, which included type and distribution of all retinal breaks, area of detachment, grade of PVR, and presence or absence of choroidal detachment was done for every case.

Inclusion criteria

Patients with primary RD with inferior breaks with or without macular detachment were eligible for inclusion in the study. The breaks included inferior single or multiple breaks, which were horse shoe-shaped between 4 and 8 o'clock with or without PVR stage A or B.

Exclusion criteria

Previous RD surgery, giant tears, PVR stage C, and age less than 18 years comprised the exclusion criteria.

First group: Standard three-port vitrectomy was carried out using the wide-angle viewing system Oculus BioM (Oculus Surgical Inc., 56ZNW Mercantile place, st. 104 Port st. Lucie, FL 34986, USA). All vitreous traction on all retinal tears was relieved. A fluid/air exchange was performed through the most accessible retinal breaks or through retinotomy. The primary break and the drainage site were treated with endolaser. All patients in this group underwent endolaser barrage 360°. Silicone oil was injected. Patients were postured face down for 10 days.

Second group: An encircling 240 scleral band or 506 sponge for large lower breaks and multiple breaks was applied for all patients in this group. Thereafter, a standard three-port vitrectomy was carried out using the wide-angle viewing system (Oculus BioM). All vitreous traction on all retinal tears was relieved. A fluid/air exchange was performed through the most accessible retinal breaks or through retinotomy. The primary break and drainage site were treated with cryotherapy or endolaser. Silicone oil was injected. Patients were postured face down for 10 days.

Intraoperative and postoperative complications and recurrence rate were recorded; follow-up was carried out for 6 months.

Silicone oil was removed after 6 months; recurrent RD was recorded in two cases (10%) in the first group and in one case (5%) in the second group. All recurrent cases were managed by vitrectomy again.


  Results Top


Forty eyes of 40 patients who had primary RD with inferior breaks were divided into two groups; each group included 20 patients.

The mean age of the patients in the first group was 56.2 years, whereas the mean age of the patients in the second group was 55.3 years.

The number of female patients was nine (45%) in the first group and eight (40%) in the second group.

Six eyes (30%) were pseudophakic in the first group, whereas eight eyes (40%) were pseudophakic in the second group.

Macula off was recorded in 16 eyes (80%) in the first group and in 17 eyes (85%) in the second group.

Nine eyes (45%) presented with one break in the first group and eight eyes (40%) presented with one break in the second group, whereas more than one break was recorded in 11 patients (55%) in the first group and in 12 patients (60%) in the second group.

In the first group, five eyes (25%) presented with one quadrant detachment, whereas the other 15 eyes (75%) presented with more than one quadrant detachment. In the second group seven eyes (35%) presented with one quadrant detachment, whereas the other 13 eyes (65%) in this group presented with more than one quadrant detachment [Table 1].
Table 1 Patients' data

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Intraoperative complications were recorded; choroidal hemorrhage was recorded in only one case (5%) in the second group, accidental scleral perforation occurred in one case (5%) in the second group, and vitreous incarceration was recorded in only one case (5%) of each group.

Intraoperative lens injury was recorded in one case (5%) in the first group, and phacoemulsification was performed. Intraoperative iatrogenic retinal break was recorded in two cases in each group (10%) [Table 2].
Table 2 Intraoperative complications

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Operative time was recorded in every case; operative time was longer in the second group than in the first group [Table 3].
Table 3 Operative time

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Early postoperative complications were recorded; recurrent RD was recorded in one case (5%) in the second group and in two cases (10%) in the first group.

Other early postoperative complications such as diplopia, buckle exposure, and anterior segment ischemia were not recorded in either group. Postoperative hypotony occurred in two cases (10%) in the first group and in one case (5%) in the second group [Table 4].
Table 4 Early postoperative complications

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Complicated cataract occurred in two cases (10%) in the first group and in one case (5%) in the second group in the first 3 months of follow-up. Increased intraocular pressure occurred in one case (5%) in the first group and in three cases (15%) in the second group. Postoperative PVR was recorded in one case (5%) in the second group and in two cases (10%) in the first group [Table 5].
Table 5 Late postoperative complications

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Success rate in the first group was 90%, whereas in the second group it was 95% [Table 6] and [Table 7].
Table 6 Success rate after 3 months' follow-up

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Table 7 Success rate after silicone oil removal after 6 months

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  Discussion Top


Generally, PPV combined with SB is the standard treatment for RD with severe PVR and for RD with inferior breaks [9] . During the past decade, several authors addressed the view of PPV and gas alone without SB as a safe and effective form of treatment for uncomplicated RD with inferior breaks [10] .

Moreover, PPV has been successfully used without SB for complicated RD such as pseudophakic RD and RD with PVR [11] .

In this study, we compared PPV with endolaser barrage 360° and PPV with SB for primary RD with inferior breaks as regards intraoperative and postoperative complications and recurrence rate.

In this study, we noticed that the operative time in the first group was relatively shorter than that in the second group.

PPV with SB has an increased risk for choroidal hemorrhage and accidental perforation, [12] requires a longer time, and has all associated complications of SB, such as exposure, refractive change, diplopia, and possible anterior segment ischemia [13] .

In the present study, choroidal hemorrhage was recorded in 5% of cases in the second group and accidental scleral perforation occurred in 5% of cases, whereas vitreous incarceration occurred in 5% of cases in each group. Recorded operative time was longer in the second group than in the first group.

Intraoperative iatrogenic retinal break was recorded in 10% of cases in each group in this study, which were successfully treated with endolaser. Sheng et al. [14] recorded iatrogenic retinal breaks, the incidence rate of which was 42.5%.

Machemer et al. [15] showed that the achievement of retinal reattachment occurred by three aspects - relief from traction, alteration of interocular currents, and chorioretinal adhesion. In this study, all vitreous was completely removed, all traction was completely released, and endolaser or cryotherapy was performed for all breaks. Some authors stated that tamponade agents should close the retinal breaks within the early hours after surgery; after that time fluid will not enter the subretinal space through the break and chorioretinal adhesion can be achieved with photocoagulation or cryopexy.

PVR was recorded in 5% of cases in the second group and in 10% of cases in the first group. It was consistent with the results of several studies that showed that PVR is still the most common cause of failure of surgery for rhegmatogenous retinal detachment [16] . Previous studies showed that the incidence of postoperative PVR varied between 2.5 and 28% in different series with different inclusion criteria [17] .

Furthermore, hypotony is a potentially devastating complication of retinectomy surgery [18] . Previous studies found the risk for hypotony after retinectomy to range from 11 to 31%. In this study, hypotony occurred in 10% of cases in the first group and in 5% of cases in the second group.

The final success rates were between 26 and 67.3% in RD with inferior breaks [19] . Sharma et al. [20] stated that a nonbuckle procedure for RD with inferior breaks can produce an 81.3% primary success and a 95.8% final success rate. In this study, success rate in the first group was 90%, whereas that of the second group was 95%. After 3 months the same results after silicone oil removal were recorded.


  Conclusion Top


This study has shown that acceptable success rates can be achieved using PPV with endolaser barrage 360° to treat primary RD with inferior breaks. Supplementory SB is unecessary to support the inferior retina as enddaser barrage with silicon oil and good positioning achieve tamponade of the breaks satisfactorily.

Also PPV with endolaser barrage 360° for treatment of RD with inferior breaks has fewer intraoperative and postoperative complications compared with PPV with SB.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.
Schwartz SG, Kuhl DP, McPherson AR, et al. Twenty-year follow up for scleral buckling. Arch Ophthalmol 2002; 120:325-329.  Back to cited text no. 1
    
2.
Lois N, Wong D. Pseudophakic retinal detachment. Surv Ophthalmol 2003; 48:467-487.  Back to cited text no. 2
    
3.
Abdullah AS, Jan S, Qureshi MS, et al. Complications of conventional scleral buckle occurring during and after treatment of rhegmatogenous retinal detachment. J Coll Physicians Surg Pak 2010; 20:321-326.  Back to cited text no. 3
    
4.
Avitable T, Longo A, Lentini G, Reibaldi A. Evaluation of possible risk factors for retinal re-detachment after silicone oil removal. Br J Ophthalmol 2008; 92:1479-1482.  Back to cited text no. 4
    
5.
Ambersin A, Wolfensberger TJ, Vobey EH. Management of giant retinal tears with vitrectomy, internal tamponade and peripheral 360 degree retinal photo-coagulation. Retina 2003; 23:622-628.  Back to cited text no. 5
    
6.
Tabandeh H, Sullivan PM, Smahlium P, et al. Suprachoroidal hemorrhage during pars plana vitrectomy-risk factors and outcome. Ophthalmology 1999; 106:236-242.  Back to cited text no. 6
    
7.
Hakin KN, Lavin MJ, Leaver PK. Primary vitrectomy for rhegmatogenous retinal detachment. Graefes Arch Clin Exp Ophthalmol 1993; 231:344-346.  Back to cited text no. 7
    
8.
Yoshida A, Feke GT, Green GJ, et al. Retinal circulatory changes after scleral buckling procedures. Am J Ophthalmol 1983; 95:182-188.  Back to cited text no. 8
    
9.
Wickham L, Connor M, Aylward GW. Vitrectomy and gas for inferior break retinal detachments: are the results comparable to vitrectomy, gas and scleral buckle. Br J Ophthalmol 2004; 88:1376-1379.  Back to cited text no. 9
    
10.
Tanner V, Minihan M, Williamson TH. Managemnt of inferior retinal breaks during pars plana vitrectomy for retinal detachment. Br J Ophthalmol 2001; 85:480-482.  Back to cited text no. 10
    
11.
Martinez-Castillo V, Verdugo A, Boixadera A, et al. Management of inferior breaks in pseudo-phakic rhegmatogenous retinal detachment with pars plana vitrectomy and air. Arch Ophthalmol 2005; 123:1078-1081.  Back to cited text no. 11
    
12.
Flindal EJ, Norton EW, Curtin DT, Gass JD. Reduction of extrusion and infection following episcleral silicone implant and cryopexy in retinal detachment surgery. Am J Ophthalmol 1971; 71:823-837.  Back to cited text no. 12
    
13.
Dominz Y, Chana M, Avni I. Corneal surface changes after pars plana vitrectomy and scleral buckling surgery. J Cataract Refract Surg 2001; 27:868-872.  Back to cited text no. 13
    
14.
Sheng Y, Sun W, Mo B, et al. Non buckled vitrectomy for retinal detachment with inferior breaks and proliferative vitreoretôpathy. Int J Ophthalmol 2012; 5:591-595.  Back to cited text no. 14
    
15.
Machemer R, Olk J, Grand M, et al. Vitrectomy without scleal buckling for primary rhegmatogenous retinal detachment. Am J Ophthalmol 1984; 98:681-693.  Back to cited text no. 15
    
16.
Pastor JC. Proliferative vitreoretinopathy: an overview. Surv Ophthalmol 1998; 43:3-18.  Back to cited text no. 16
    
17.
Heimann H, Zou A, Jandeck C, et al. PVR as a complication of rhegmatogenous retinal detachment. Grafes Clin Exp Ophthalmol 2006; 244:69-78.  Back to cited text no. 17
    
18.
Tan HS, Mura M, Oberstein SY, de Smet MD. Air versus gas tamponade in retinal detachment surgery. Am J Ophthalmol 2010; 149:447-452.  Back to cited text no. 18
    
19.
Thompson JA, Snead MP, Billington BM, et al. National audit of the outcome of primary surgery for rhegmatogenous retinal detachment. Eye 2002; 16:771-777.   Back to cited text no. 19
    
20.
Sharma T, Challa JK, Ravishankar KV. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol 2004; 88:1372-1375.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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Abstract
Introduction
Patients and methods
Results
Discussion
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Acknowledgements
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