Abstract
Purpose: To evaluate the anatomic and visual outcomes of primary vitrectomy for rhegmatogenous retinal detachment (RRD) repair using no amount of postoperative prone positioning to clarify the role of face-down posturing for RRD reattachment. Methods: This retrospective consecutive interventional case series comprised patients who had primary vitrectomy for RRD repair. The surgical outcomes, single-surgery anatomic success rate, and postoperative best-corrected visual acuity (BCVA) were assessed. The primary objective was to evaluate the anatomic and visual outcomes of vitrectomy RRD reattachment using no postoperative prone positioning. Results: This study comprised 116 eyes of 116 patients. Single-surgery anatomic success was achieved in 112 (96.5%) of 116 eyes. The single-surgery anatomic success rate was 100% in phakic patients (n = 56) and 93% in pseudophakic patients (n = 60), with both groups having an improvement in the mean BCVA. Conclusions: Primary vitrectomy with no postoperative prone positioning is a successful surgical intervention for RRD repair. The anatomic closure rate in this study is one of the highest reported in the literature and involved a large number of macula-off RRDs, with minimal complications and a significant improvement in BCVA, primarily using 14% perfluoropropane for gas tamponade.
Keywords: retinal detachment, vitrectomy, postoperative positioning
Introduction
The single-surgery anatomic success rates for rhegmatogenous retinal detachment (RRD) repair using standard treatment methods have historically been over 90%.1 –9 Primary pars plana vitrectomy (PPV) with endolaser application and postoperative intraocular gas tamponade has continued to increase in popularity as the preferred treatment for uncomplicated RRD because of excellent single-surgery anatomic success rates and decreased patient discomfort.1 –5,10 Although such studies sought to elucidate the efficacy of primary PPV in the setting of RRD, there is less discussion on how postoperative prone positioning, especially the lack thereof, affects single-surgery anatomic success rates and visual outcomes for RRD patients in the modern microincision vitrectomy surgery (MIVS) era.
RRD repair with postoperative prone positioning has been described since 1986.1,11 Since then, MIVS has evolved into the most common surgical intervention for RRD repair with the addition of endolaser application and intraocular gas tamponade (eg, 20% sulfur hexafluoride [SF6]; 14% perfluoropropane [C3F8]) with strict postoperative face-down positioning.1 –8,10 These adaptations have improved the rate of successful primary vitrectomy for RRD to approximately 90%,1 –4,8,10 with face-down positioning lasting between 7 days and 14 days.1,3,4
Still, maintaining face-down positioning is a major complaint of patients having vitreoretinal surgery and is associated with poor patient compliance.3 –5,12,13 Therefore, the evolution in vitreoretinal surgery requires updates on using positioning of a shorter duration while preserving exceptionally high surgical success rates.
This retrospective consecutive interventional case series examined the anatomic and visual outcomes of primary vitrectomy for RRD repair with no postoperative prone positioning.
Methods
This retrospective study evaluated consecutive patients recruited from Erie Retinal Surgery, Erie, PA, USA. Inclusion criteria were patients 18 years or older with RRD and symptoms for less than 3 months. Exclusion criteria included significant cataract or vitreous hemorrhage precluding satisfactory evaluation of the macula, previous vitrectomy surgery, traumatic RD, RD with more than 1 retinal break in all 4 quadrants, high myopia, and concurrent retinal conditions that might limit vision (eg, grade C proliferative vitreoretinopathy [PVR], retinal vein occlusion, proliferative diabetic retinopathy, neovascular age-related macular degeneration, hereditary RD). All patients received a full ocular examination, including best-corrected visual acuity (BCVA), intraocular pressure (IOP), and dilated depressed evaluation, during the first preoperative visit.
Subsequently, all patients had standard 3-port sutureless 25-gauge PPV by the same surgeon (D.A.) using 1 of 3 vitreoretinal surgical platforms (Eva and Eva Nexus, DORC; Constellation, Alcon; Stellaris Elite, Bausch + Lomb). As per the surgeon’s preference, subretinal fluid (SRF) drainage through an existing retinal break was performed; no peripheral or posterior drainage retinotomy sites were created for drainage of SRF in any case. In all cases, primary vitrectomy without cataract surgery and appropriate intraoperative laser retinopexy of relevant retinal breaks were performed. Areas of lattice, with or without holes or breaks, were treated with laser retinopexy intraoperatively. Scleral depression, 360-degree endolaser application to the retinal periphery, and truncation of tears were performed. No simultaneous cases were performed, there were no attempts at complete SRF removal, no drainage retinotomies were performed, and no perfluoro-N-octane was used.
All patients were given standardized postoperative instructions, with a strong emphasis that no positioning was required and that the patients must not sleep on their back. After surgery, patients were assessed at 14 days (initial follow-up), 8 weeks, and 4 months (final follow-up) by the retina surgeon who performed all operations. There was no variation in technique (single surgeon), and no additional qualifiers or instructions were used for RDs with inferior breaks given the study design of consecutive cases. The single-surgery anatomic success rate, complications, and postoperative BCVA were evaluated. The primary outcome measure was single-surgery anatomic success, which constituted surgery that required only a single attempt to achieve permanent retinal reattachment, excluding second surgeries for silicone oil (SO) removal.
All data were entered into an Excel database (Microsoft Corp) and analyzed using the single-surgery anatomic success rate, which was the primary outcome measure. The preoperative and postoperative BCVA and IOP measurements were analyzed using 2-tailed paired t tests with means (±SD), proportions, and corresponding 95% CIs. Regression analysis was performed to identify a possible association between VA and study parameters.
Results
Patient Demographics and Characteristics
The study included 44 eyes of 44 women (37.9%) and 72 eyes of 72 men (62.1%). The mean patient age was 63.4 ± 11.8 years (range, 20-87 years). There were 60 right eyes (51.7%) and 56 left eyes (48.3%). Of the eyes, 56 (48.3%) were phakic and 60 (51.7%) pseudophakic. At the initial preoperative presentation, 33 patients (28.5%) had macula-on RRDs and 83 (71.5%) had macula-off RRDs. Twenty-one eyes (18%) had lattice degeneration; the details (eg, clock hours, anterior–posterior location) were not recorded.
The intraocular tamponade was with 14% C3F8 gas in 106 eyes (91.4%); 54 (96.4%) of these eyes were phakic, and 52 (86.7%) were pseudophakic. Five patients (4.3%) were treated with 20% SF6 gas tamponade and 5 (4.3%) with 1000 cs SO; 2 phakic patients (3.6%) received SF6 or SO, and 8 pseudophakic patients (13.3%) were treated SF6 or SO. All gas bubbles provided 90% or greater tamponade on postoperative day 1. Five RDs had inferior breaks (100% single-surgery anatomic success) and were treated with C3F8; 2 were macula-on detachments, and 3 were macula-off detachments. Of the 7 eyes with a total RD (detachment of entire retina), 4 were treated with SO, 2 with C3F8, and 1 with SF6. One patient with a total RD required a second RD repair.
The median initial follow-up was 4 months (range, 1-36 months; mean, 7.9 ± 7.6 months). The median final follow-up was 10 months (range, 1-36 months; mean, 11.9 ± 9.5 months).
Single-Surgery Anatomic Success Rate
Single-surgery anatomic success was achieved in 112 (96.5%) of the 116 eyes. The rate was 100% in phakic patients (n = 56) and 93.3% in pseudophakic patients (n = 56). Excluding follow-ups of less than 3 months, single-surgery anatomic success was achieved in 102 (96.2%) of the 106 eyes at all follow-ups. At presentation, 17 phakic eyes (30.4%) had a macula-on RRD and 39 (69.6%) had a macula-off RRD. In the pseudophakic group, 16 eyes (26.7%) and 44 eyes (73.3%) presented with a macula-on RRD and a macula-off RRD, respectively. No phakic patient required second vitreoretinal surgical procedures, and 32 phakic patients (57%) received cataract surgery during the follow-up period.
Visual Acuity
The mean preoperative logMAR VA was 1.5 ± 1.1 (phakic group, 1.4 ± 1.1; pseudophakic group, 1.5 ± 1.1). The mean postoperative logMAR VA was 1.0 ± 0.8 (phakic group, 1.1 ± 0.6; pseudophakic group, 0.9 ± 0.7). There was a statistically significant decrease (ie, improvement) in the logMAR BCVA (mean decrease, 0.6 ± 1.2; 95% CI, 0.4-0.8; P < .001 or 9.6 × 10−8, 2-tailed paired t test). In the entire cohort, 33 eyes (28.5%) had a BCVA of 20/50 or better (logMAR ≤0.4) preoperatively. Postoperatively, 42 eyes (36.2%) had a BCVA of 20/50 or better.
Complications
There were no serious intraoperative complications or adverse events. There was no statistically significant difference between the preoperative IOP and postoperative IOP (range, 8-36 mm Hg and 7-34 mm Hg, respectively; 2-tailed paired t test). No eye had an IOP elevation greater than 40 mm Hg. Four eyes (3.5%) required a second surgery for retinal reattachment complicated by PVR. Clinical evaluation and statistical analysis did not find a relationship with no postoperative prone positioning and PVR occurrence or progression.
Conclusions
Many ophthalmologists consider postoperative prone positioning for RRD repair using intravitreal tamponade to be a requirement for proper reattachment of retinal tissue.4,5,10 –14 Several sources suggest improved single-surgery anatomic success rates (>90%) for RD repairs using PPV with intravitreal tamponade and mandatory postoperative prone positioning of various durations (short term, ≤7 days; long term, >7 days).1 –5,10 –13 With advances in vitreoretinal surgical tools and techniques, such as MIVS and endolaser treatment, the historical role of postoperative prone positioning for retinal reattachment after RRD repair has recently been brought into question.5,10,14
The results in our study challenge the benefit of postoperative prone positioning for RRD repair, showing high single-surgery anatomic success rates and statistically significant improvements in BCVA with no prone positioning postoperatively. Our consecutive interventional case series has one of the highest single-surgery anatomic success rates the in current literature for patients with no postoperative prone positioning after RRD repair using PPV, endolaser application, and intravitreal tamponade. Although the VA improved overall with this technique, our study was not designed to assess whether our VA improvement results were different from those with postoperative prone positioning.
In our study, 2 cases with SO tamponade responded well with no postoperative prone positioning. However, because these represent only 2 datapoints, these results warrant further study for statistical significance and were therefore excluded from our discussion. Cases with SO were included to respect the a priori methodology design of including sequential cases, and SO was chosen for these patients because of the need for long-term tamponade (eg, traveling). Moreover, although our series comprised a sizable group of consecutive patients with RRD, it is limited by the retrospective methodology construct.
In conclusion, we found favorable outcomes of primary PPV for RRD repair with no postoperative prone positioning. Moreover, our results reinforce the need to clarify and reevaluate the role of postoperative prone positioning with modern MIVS surgical platforms. Based on our results, PPV, endolaser application, and tamponade with SF6 or C3F8 gas followed by no postoperative prone positioning is a useful intervention with a single-surgery anatomic success rate of 96.5% and a statistically significant improvement in BCVA with minimal complications.
Footnotes
Ethical Approval: This study was conducted in accordance with the Declaration of Helsinki and did not require ethical clearance. All patient information was de-identified, and the collection and evaluation of all protected health information were performed in a US Health Insurance Portability and Accountability Act–compliant manner.
Statement of Informed Consent: Informed consent was not required because the study did not use patient-identifying information. Patients provided informed consent for diagnosis, treatment, and follow-up.
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Almeida: Acelyrin, Alcon, Alimera Sciences, Allergan/Abbvie, Bausch + Lomb, Bayer, Boehringer Ingelheim, Citrus Therapeutics, Clinical Trials Network, EyePoint Pharmaceuticals, Inc, Genentech, Gyroscope Therapeutics, Novartos, Ocugen, Opthea, Regeneron, RegenXBio, Roche, Samsara Vision, Spherix Consulting Group. Dr. Chin: Alimera Sciences, Allergan, Bayer, Citrus Therapeutics, Genentech, Hexal AG/Sandoz Inc, Iveric Bio, Kodiak Sciences, Novartis, Opthea, Regeneron. None of the other author(s) declared potential conflicts of interest with respect to the research, authorship, and/or publication of the article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
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