Etiology of retinal detachment and comparison of visual outcome after pars plana vitrectomy and scleral buckling surgical procedures

Abstract

Purpose

The study is based on finding better treatment options and diagnostic methods for the particular type of retinal detachment (RD).

Methods

A cross-sectional comparative study was conducted at the Ophthalmology department of Holy Family Hospital, Rawalpindi from July 2023 to March 2024. Visual prognosis after surgery was calculated on the basis of a comparison of pre-operative and post-operative visual acuity. A total of 88 patients of both genders irrespective of age were included through consecutive non-random sampling techniques. Different diagnostic procedures were performed to evaluate the cause of Retinal Detachment. Pre-operative and Post-operative visual acuity was noted in comparison of two different surgical procedures.

Results

Among 88 patients 60% were males and 40% were females. According to the different causes of RD, RD with PDR (40%), RD with pseudophakia (20%), RD with Proliferative vitreoretinopathy (17%), RD with trauma (13%), RD with myopic degenerations (10%) were included. Visual acuity after surgery improved in 61 subjects, 35 patients with pars plana vitrectomy with silicon (PPV + SO) procedure and 26 patients with scleral buckling + cryotherapy (SB + Cryo) procedure and remained unchanged in 27 subjects, 9 with PPV + SO procedure and 18 with SB + Cryo procedure. There was a significant difference between the visual acuity of patients with PPV + SO and SB + Cryo surgical procedures, p < 0.05.

Conclusions

The main cause or risk factor of retinal detachment or tear/hole and the type of RD were found. There is a significant difference in the Visual acuity of the patients following PPV + SO and SB + Cryo surgery.

Introduction

The retina is a multilayered sensory tissue of the dorsal eyeball onto which the light entering the eye is targeted, forming a reversed and inverted image. The neural retina is highly ordered into six fundamental neurons: photoreceptors, amacrine cells, bipolar cells, muller cells, horizontal cells, and ganglion cells [1]. The fovea is a small depression, approximately 1.5 mm at the center of the macula, and responsible for high acuity vision [2]. The term Retinal detachment is used to define the separation of the neurosensory retina from the intrinsic layer, retinal pigment epithelium (RPE) by subretinal fluid (SRF). Retinal detachment is a consequential event, which may result in complete blindness or loss of vision. The outer covering of the photoreceptor receives nutrients and oxygen from the choroid. Photoreceptors do not work if the retina is separated from the choroid [3]. If the retina is re-attached without delay, then good vision can be retained [4]. Rhegmatogenous retinal detachment is the Separation of neurosensory retina from RPE in the presence of a complete thickness retinal break and subsequent accumulation of subretinal fluid. Retinal break (‘rhegma’, meaning rent or a fissure) occurs and fluid passes from the vitreous cavity into the possible space under the retina which leads to the separation of the retina from the choroid [5]. PVD is broadly considered to be a serious element in the formation of a retinal tear. Lattice degeneration is another weak risk factor for rhegmatogenous RD [6]. Tractional retinal detachment (TRD) represents an advanced form of proliferative diabetic retinopathy that results from neovascular growth from already present retinal blood vessels. Vascular endothelial growth factors create a suitable environment for angiogenesis [7]. TRD is commonly classified as macular TRD, extra‑macular TRD, and long‑standing macular TRD. Tractional retinal detachment with the involvement of the macula, patients may experience rapid visual loss and worse visual outcomes [8]. Combined RD is characterized by a detachment that extends to the ora serrata and traction from full‑thickness retinal breaks that convert a mere traction detachment to one with a rhegmatogenous component [9]. Separation of the retinal layer from RPE around the macula and peripheral retina is attached known as central retinal detachment. The detachment may be minimal (perifoveal fluid has a macular hole) or widespread (staphyloma with high myopia). Exudative type of RD is caused by fluid production from the back of the retina instead of fluid coming from the vitreous cavity. Retinal break or traction is not present. Exudative or secondary RD is caused by inflammation (uveitis), tumor, injury, and accumulation of fluid or absence of break inside the retina. Hemorrhagic Retinal detachment separation of two retinal layers caused by blood accumulation in subretinal space merely, in the absence of traction or retinal break if either is, it is secondary and not causative. Hemorrhagic retinal detachment due to trauma with severe posterior segment injury may prevent successful visual rehabilitation. Retinal detachment affects ~ 1 per around ten thousand per year [10, 11]. Several studies have identified a family history of RD as a major risk factor, with the likelihood of contralateral eye involvement increasing over time [12, 13]. Other significant factors contributing to RD include high myopia, posterior vitreous detachment (PVD), ocular trauma, and previous cataract surgery, with myopia greater than − 3 D increasing the risk tenfold [14, 15]. Additionally, post-cataract surgery complications and traumatic causes have been associated with an elevated risk of RD, with symptoms often presenting as painless, abrupt vision loss, floaters, or flashes [16–18].

In children and teenagers, RD may be asymptomatic initially and is diagnosed due to the presence of redness, squint, and white pupillary reflex (leukocoria) due to the accelerated progression of cataracts. Relative afferent pupillary defect is present when there is total detachment. Anterior vitreous shows tobacco dust-like opacities (Shaffer’s sign positive). The practice of diagnosing RD is by direct and indirect ophthalmoscopy with scleral indentation. Retinal detachment is recognized by loss of the red fundus glow and the retina appears grey with marked elevation of retina. If the macula is attached, patients must have surgery in one day to prevent macular detachment and permanent blindness. In Ocular Bscan ultrasonography, Goldmann three mirrors are used to diagnose the interior retina. Detachment of the retina is commonly cured by mechanical methods such as scar-induced sealing off all gaps in the retina. Various procedures are available as Cryotherapy, Laser coagulation, scleral buckling, and vitrectomy to close retinal breaks. The cryotherapy procedure involves freezing of eyeball with the application of a cryoprobe (–80 °C). In the case of retinal holes and gaps, a silicon band can be used to cover the eyeball called an encircling band [19, 20]. Distortion of the eyeball with the variation in refraction is the most common complication in procedures of scleral buckling. After the operation, problems in eye movement and diplopia cases are reported around 15% [21]. The most frequent complication is cataract in 80% of cases in the first year after vitrectomy and it also develops the accidental retinal holes during vitrectomy in 15% of cases [22, 23]. Retinal detachment is a significant ophthalmic emergency characterized by the separation of the neurosensory retina from the underlying retinal pigment epithelium, disrupting normal visual processing and potentially leading to irreversible vision loss if not promptly treated. The primary types of RD include rhegmatogenous, tractional, and exudative, with rhegmatogenous retinal detachment being the most prevalent, often caused by retinal tears or holes that allow vitreous fluid to accumulate under the retina. Risk factors for RRD include high myopia, ocular trauma, previous cataract surgery, and peripheral retinal degeneration. The main surgical treatments for RD are pars plana vitrectomy (PPV) and scleral buckling (SB). PPV involves the removal of the vitreous gel and repair of retinal tears, often supplemented with gas or silicone oil tamponade, while SB uses an external buckle to indent the sclera, thus closing the retinal break. Both procedures aim to reattach the retina and restore vision but differ in technique and indications. Recent studies have highlighted the effectiveness and outcomes of these surgical techniques. A meta-analysis by Eshtiaghi et al. (2022) found that PPV, both alone and in combination with SB, provides high anatomical success rates for RRD repair, with the choice of technique depending on specific patient and detachment characteristics [24]. Additionally, a study by Popovic et al. (2022) [21] compared PPV, SB, and pneumatic retinopexy, concluding that while PPV is often preferred for its high success rate and lower complication risk, SB remains valuable in certain cases, especially in younger patients and those with uncomplicated RRD [25]. Research in 2023 continues to support these findings, with Ryan et al. (2023) [22] emphasizing the importance of personalized treatment plans, noting that PPV is often favored for its visual outcomes, particularly in cases where rapid visual recovery is desired [26]. Another study highlighted that combining SB with PPV can be beneficial in pediatric cases due to the difficulty of complete vitreous removal in the presence of a natural lens, thus reducing vitreoretinal traction and improving anatomical success [27, 28].

Materials and methods

A cross-sectional comparative study was conducted at the Department of Ophthalmology, Holy Family Hospital, Rawalpindi, from July 2023 to March 2024. The study was approved by the Institutional Board of Ethics, Holy Family Hospital, Islamabad, and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the participants aged 16 to 55, before their inclusion in the study. In the case of minors (individuals under the age of 16), informed consent to participate was obtained from their parents or legal guardians, in accordance with ethical guidelines.

Inclusion and exclusion criteria

The inclusion criteria for the study comprised patients aged 12 to 55 years, of both genders, individuals with a history of ocular trauma or previous ocular surgery, those presenting with painless vision loss, patients with congenital ocular anomalies, and individuals diagnosed with diabetes mellitus. Additionally, patients with tractional and rhegmatogenous retinal detachment (RD) requiring surgical intervention were included.

Conversely, the exclusion criteria involved non-cooperative patients or those with mental disabilities, as well as patients unwilling to participate in the study. Furthermore, given that exudative RD in most cases does not require surgical intervention, patients diagnosed with exudative RD due to inflammatory or vascular causes without retinal tears or traction were excluded from the surgical comparison. Only cases where surgical management was necessary were included in the final analysis to maintain the study’s focus on tractional and rhegmatogenous RD.

The study included a total of 88 patients of various ages with different causes of RD, including trauma, pseudophakia, posterior vitreous detachment (PVD), proliferative diabetic retinopathy (PDR), proliferative vitreoretinopathy (PVR), myopia, and systemic hypertension. Patients were selected through a consecutive non-random sampling technique, and informed consent was obtained from all participants who met the inclusion criteria.

Perioperative setting

Data on patients exposed to diagnostic criteria for specific types of retinal detachment were recorded on a specially designed proforma. The medical history of RD surgery patients, including those with at least one month of follow-up and systemic diseases such as diabetes and hypertension, was documented. Pre-operative and post-operative visual acuity was assessed using Snellen’s acuity chart.

Complete ocular evaluations were performed using slit-lamp examination with a 90D lens and direct or indirect ophthalmoscopy. Fundus photographs were taken using a fundus camera to visualize retinal status and complications before and after surgery. Ocular B-scan ultrasonography was employed to diagnose RD in eyes with opaque media and any associated pathology, such as intraocular foreign bodies or PVR. Intraocular pressure was measured using tonometry, and the confrontation test was used to detect visual field defects.

Statistical analysis

The surgical treatment options were pars plana vitrectomy with internal tamponade (PPV + SO) and scleral buckling with cryotherapy (SB + cryo). Statistical data were analyzed using SPSS 20. The statistical significance of the comparison of visual outcomes between the two surgical procedures (PPV + SO and SB + cryo) was calculated using the chi-square test to determine whether the difference in visual acuity was significant. The statistical analysis (Chi-square test) was performed to observe the comparison of both procedures. It showed that the calculated Pearson Chi-Square value was 4.32. As calculated Chi-Square value was greater than 3.84 with df = 01. Hence, the alternate hypothesis was accepted. A significant difference (p < 0.05) between the visual acuity of the patients with PPV + SO and SB + cryo surgical procedures was observed.

Results

This study was designed to find out the frequent causes of retinal detachment and the outcome of visual status after surgery in patients presenting at the ophthalmology department of Holy Family Hospital Rawalpindi, Pakistan. A total of 88 patients, 52 males and 36 females presented with RD were taken as a studied group. The percentage of the patients presented with a macula partly or completely attached and macula off was observed to be 84% and 16% respectively.

The type wise distribution of RD among a studied group of patients is expressed in Table 1. Tractional RD showed the highest percentage (40%) followed by rhegmatogenous retinal detachment RRD (26%), Combined TRD + RRD (17%) and Traumatic RD (13%) of prevalence in studied subjects. However, 4% of patients were observed to show an Exudative type of retinal detachment.

Table 1.

Type-wise prevalence of retinal detachment in studied subjects

Types of RD	Prevalence
TRD	40%
RRD	26%
Combined TRD + RRD	17%
Traumatic	13%
Exudative RD	4%

*RD = Retinal detachment; TRD = tractional retinal detachment; RRD = rhegmatogenous retinal detachment

The etiology of RD among studied patients is presented in Table 2. Proliferative diabetic retinopathy (PDR) was observed in (40%) of patients followed by psuedophakia (20%), proliferative vitreoretinopathy PVR (17%), trauma (13%) and myopic degenerations (10%). Associated complications in patients of RD were dislocated intraocular lens (IOL) in 4% of patients, however, inner eye inflammation and vitreous hemorrhage were found to be 9% and 11% respectively.

Table 2.

Etiology of retinal detachment and its associated complications in studied subjects

Causes	Prevalence
PDR	40%
Pseudophakia	20%
PVR	17%
Trauma	13%
Myopic degenerations	10%
Associated complications with RD
Dislocated IOL	4%
Inner eye inflammation	9%
Vitreous haemorrhage	11%

*PDR, proliferative diabetic retinopathy; PVR, proliferative vitreoretinipathy; IOL, intraoccular lens

To observe the efficacy of the surgical procedures, 44 patients out of 88 were selected with the treatment of pars plana vitrectomy (PPV + SO), and 44 patients were selected with the treatment of scleral buckling with cryotherapy (SB + cryo). The comparison among surgical procedures was drawn by visual status after surgery.

The comparison of pre and post-operative visual activity for both studied procedures i.e. PPV + SO and SB + cryo is presented in Fig. 1 and Fig. 2 respectively. Presentation of pre-op PPV + SO procedure, visual acuity (> 6/18) was observed in 2.2% subjects, 6/18 to 6/36 in 23% subjects, 6/60 to CF (counting fingers) in 32% subjects, CFCF (counting fingers close to face) to HM in 36% subjects, PL (perception of light) in 6.8% subjects. Before the scleral buckling procedure, visual acuity > 6/18 was observed in 9.1% of subjects, 6/18 to 6/36 in 27.3% of subjects, 6/60 to CF in 34.1% of subjects, CFCF to HM in 25% of subjects and PL in 4.5% subjects. In PPV + SO, post-operative visual acuity > 6/18 was observed in 25% of subjects, 6/18 to 6/36 in 32% of subjects, 6/60 to CF in 20.5% of subjects, CFCF to HM in 18% of subjects, and PL in only 4.5% subjects with the.

Fig. 1.

Comparison of Visual acuity pre and post-pars plana vitrectomy surgical procedure

Fig. 2.

Comparison of Visual acuity pre and post-scleral buckling surgical procedure

In the scleral buckling procedure, post-operative visual acuity > 6/18 was observed in 34% of subjects, 6/18 to 6/36 in 27.3% of subjects, 6/60 to CF in 18.2% of subjects, CFCF to HM in 16% subjects and PL in 4.5% subjects. After the surgical procedure, the retina was attached in 90% of cases in both procedures, and few were presented with elevation in intraocular pressure (IOP), vitreous hemorrhage, choroidal detachment, and cataract.

The comparison of visual status with surgical procedures performed is explained in Fig. 3. The Expected count for improved and unchanged subjects and the result for the chi-square test are expressed in Table 3 and Table 4 respectively. In the PPV + SO procedure, visual acuity was improved in 79.5% of subjects, however, the SB + cryo procedure showed improvement in 59% of subjects. It shows that the calculated Pearson Chi-Square value was 4.32. As calculated Chi-Square value was greater than 3.84 which shows p, ≤ 0.05, and our Alternate hypothesis was accepted. There was a significant difference between the visual acuity of the patients with PPV + SO and SB + Cryo surgical procedures. Preoperative OCT scans from our study (Figs. 4 and 5) show pronounced retinal abnormalities, including intraretinal cystic changes, hard exudates, diffuse retinal swelling, and signs of tractional retinal detachment caused by vitreomacular traction. In contrast, the postoperative OCT image (Fig. 6), adapted from the referenced study, illustrates the restored foveal architecture and resolution of edema, highlighting the effectiveness of surgical intervention in similar clinical scenarios [29].

Fig. 3.

Comparison of Visual status with surgical procedure performed

Table 3.

Surgical procedure performed * Visual status after surgery cross tabulation

Surgical procedure performed		Visual status after surgery		Total
		Improved	Unchanged
PPV + SO	Count	35	9	44
	Expected Count	30.5	13.5	44.0
SB + Cryo	Count	26	18	44
	Expected Count	30.5	13.5	44.0
Total	Count	61	27	88
	Exposed Count	61.0	27.0	88.0

Table 4.

Chi-square test for the comparison of PPV + SO and SB + cryo procedures

		Value	df	Asymptotic Significance (2-sided)	Exact Sig.(2-sided)	Exact Sig. (1-sided)	Symmetric Measures
							Value	Approximate Significance
Pearson Chi-Square		4.328a	1	0.037
Continuity Correctionb		3.420	1	0.064
Likelihood Ratio		4.391	1	0.036
Fisher’s Exact Test					0.063	0.032
Linear-by-Linear Association		4.279	1	0.039
Nominal by Nominal	Phi						0.222	0.037
	Cramer’s V						0.222	0.037
N of Valid Cases		88

a. 0 cells (0.0%) have an expected count of less than 5. The minimum expected count is 13.50

b. Computed only for a 2 × 2 table

Fig. 4.

Right OCT macula shows good foveal contour. There are multiple intraretinal cystic changes & hard exudates associated with diffuse retinal swelling (shown as pink color in ETDRS sector). Photoreceptors and RPE layers appear intact. Vitreomacular traction (Tractional rational detachment) at multiple macular areas is also seen

Fig. 5.

Right OCT macula shows good foveal contour. There are multiple intraretinal cystic changes & hard exudates associated with diffuse retinal swelling (shown as pink color in ETDRS sector). Photoreceptors and RPE layers appear intact. Vitreomacular traction (Tractional rational detachment) at multiple macular areas is also seen

Fig. 6.

Postoperative OCT image demonstrating restored foveal contour with resolution of intraretinal cystic changes and retinal edema following surgical intervention [29]

Discussion

Retinal detachment is a vision-threatening disease requiring prompt diagnosis and management to prevent significant visual loss. The purpose of the current study was to diagnose patients at the non-proliferative stage of RD and provide appropriate management based on disease severity while controlling risk factors such as diabetes and trauma. The observed male-to-female ratio in this study was 3:2, aligning with Suwal’s (2019) [30] findings, which reported a ratio of 2:1. The study’s results showed that tractional RD was the most prevalent type, which contrasts with Heussen et al. (2011) [17], who reported rhegmatogenous RD as the most frequent type. Proliferative diabetic retinopathy (PDR) and pseudophakia were identified as significant risk factors for RD, similar to findings by Panday et al. (2014) [25], who reported myopia and prior cataract surgery as critical risk factors.

The study conducted at Holy Family Hospital Rawalpindi highlighted that tractional RD is the most common type, followed by rhegmatogenous RD, combined tractional and rhegmatogenous RD, traumatic RD, and exudative RD. The primary etiologies identified included PDR, pseudophakia, proliferative vitreoretinopathy (PVR), trauma, and myopic degenerations. These findings were consistent with the current study’s identification of PDR and pseudophakia as significant risk factors.

Comparing the surgical outcomes of pars plana vitrectomy with silicone oil (PPV + SO) and scleral buckling with cryotherapy (SB + cryo), significant differences in postoperative visual acuity and overall success rates were observed. Postoperative visual acuity of > 6/18 was higher in the SB + cryo group (34%) compared to the PPV + SO group (25%). However, PPV + SO showed a higher overall improvement in visual acuity (79.5%) compared to SB + cryo (59%). These findings are supported by a study by Eshtiaghi et al. (2022) [20], which found that PPV generally provides high anatomical success rates, though visual outcomes can vary based on the severity of the initial detachment and the presence of complications such as PVR. Another meta-analysis by Popovic et al. (2022) [21] indicated that PPV is often preferred for managing complex cases and providing rapid visual recovery, although SB remains effective for simpler detachments, particularly in younger patients.

In understanding the risk factors and prevention strategies for rhegmatogenous retinal detachment (RRD), it is crucial to consider findings from studies conducted in similar regions. A recent study by Al-Dwairi et al. examined the characteristics and risk factors associated with RRD in the contralateral eye and highlighted key predictive factors, including total RRD in the first eye, the presence of lattice degeneration, high-risk retinal breaks, and involvement of the inferior-nasal quadrant. Additionally, systemic conditions such as connective tissue diseases were found to contribute to RRD susceptibility. Their findings also emphasized the role of prophylactic laser retinopexy in preventing RRD in the fellow eye, reinforcing the importance of early detection and preventive measures. These insights align with our study’s findings on the etiological factors of RD and further support the need for timely intervention to improve surgical outcomes following pars plana vitrectomy and scleral buckling procedures [23].

The risk factors and progression patterns of retinal detachment have been extensively studied. A family history of RD remains a significant risk factor, with the likelihood of detachment in the contralateral eye increasing from 9 to 10% within four years [12, 13]. Furthermore, up to 10% of postmortem eyes exhibit full-thickness retinal breaks without detachment [13]. Other contributing factors include axial myopia, PVD, ocular trauma, and cataract surgery, with high myopia (> − 3 D) elevating the risk tenfold, whereas lower myopia presents a comparatively lower risk [14, 15]. Cataract surgery, despite being a routine and relatively safe procedure, has been associated with an increased risk of rhegmatogenous RD, occurring in approximately 1 out of 1000 cases, with the risk escalating sevenfold over six years [16]. Conversely, traumatic RD remains relatively uncommon [17]. Clinically, RD presents with painless vision loss, often preceded by floaters and flashes due to vitreous degeneration and retinal traction. In some cases, RD may mimic anterior uveitis, leading to diagnostic challenges [18]. These findings align with our study’s observations on the etiology and risk factors contributing to surgical outcomes in RD patients undergoing pars plana vitrectomy and scleral buckling procedures.

The study also noted complications such as increased intraocular pressure (IOP), vitreous hemorrhage, choroidal detachment, and cataract formation post-surgery, which are critical considerations for choosing the surgical technique and postoperative care. Chong and Fuller (2023) [30] emphasized the importance of tailored surgical approaches and postoperative management to minimize these risks and improve patient outcomes.

Using chi-square analysis, the study demonstrated a significant difference in visual acuity improvement between the two surgical methods, with PPV + SO showing a higher rate of improvement. This statistical validation underscores the importance of evidence-based approaches in selecting the appropriate surgical intervention for RD. In conclusion, the findings suggest that personalized treatment plans and careful management of risk factors are essential for optimizing outcomes in RD patients. This comprehensive view aligns with recent literature, highlighting the evolving preferences and outcomes associated with PPV and SB techniques.

Conclusion

The study at Holy Family Hospital Rawalpindi highlights that tractional retinal detachment (RD) is the most prevalent type, with proliferative diabetic retinopathy (PDR) and pseudophakia as significant risk factors. Comparing surgical methods pars plana vitrectomy with silicone oil (PPV + SO) shows higher overall visual improvement compared to scleral buckling with cryotherapy (SB + cryo). These findings align with recent literature, emphasizing the effectiveness of PPV in achieving better visual outcomes and managing complex cases. Personalized treatment plans and careful risk factor management are essential for optimizing RD patient outcomes.

Author contributions

All authors contributed significantly to the work reported in this manuscript. Maryam Riaz and Tanzila Rehman were responsible for the conceptualization and design of the study. Nimra Ameen conducted the experiments and collected data. Nimra Ameen along with Saira Saleem and Asma Saleem performed the data analysis and interpretation. Anam Mahmood and Ali Ahmed provided critical revisions and supervised the overall project. All authors participated in the drafting and revision of the manuscript and have approved the final version for submission.

Funding

The research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Data availability

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval and consent to participate

The study was approved by the Institutional Board of Ethics, Holy Family Hospital, Islamabad. We have obtained informed consent from the participants in accordance with the Helsinki Protocol.

Consent for participation

Informed consent to participate in this study was obtained from all participants. For minors (participants under the age of 16), consent was obtained from their parents or legal guardians.

Competing interests

The authors declare no competing interests.