Abstract
Purpose:
To investigate the anatomical success rate associated with rhegmatogenous retinal detachment (RRD) repair without postoperative head positioning.
Methods:
Data on 182 individuals undergoing pars plana vitrectomy (PPV) with or without phacoemulsification or scleral buckle for primary RRD with intraocular tamponade were retrospectively reviewed. The primary outcome was the initial anatomical success rate. Secondary outcome measures were the change in best-corrected visual acuity and the final reattachment rate.
Results:
A total of 122 eyes from 122 patients who underwent RRD repair without postoperative positioning were included in this study. PPV alone was performed in 39% of cases, whereas the remaining patients had PPV combined with phacoemulsification (35%), with scleral buckle (19%), or both (7%). Inferior breaks between the 4 o’clock and 8 o’clock positions were present in 47% of cases. Primary and final anatomical success was achieved in 86% and 98% of cases, respectively. The most common cause for redetachment was proliferative vitreoretinopathy. Age and combined inferior retinal and superior breaks were predictive of recurrence in the logistic regression model. The mean baseline best-corrected visual acuity improved from 1.2 (Snellen equivalent, 20/320) to 0.76 (Snellen, 20/125) logarithm of the minimum angle of resolution after retinal reattachment (P < .001).
Conclusions:
PPV combined with or without phacoemulsification or scleral buckle for primary RRD in pseudophakic eyes or those rendered pseudophakic is associated with good anatomical outcomes without restricted postoperative head positioning. Retinal detachment in eyes with combined retinal inferior and superior breaks may have a lower success rate, and whether this is due to lack of postoperative positioning needs further evaluation in prospective, controlled studies.
Keywords: positioning, posturing, retinal detachment, vitrectomy
Introduction
Rhegmatogenous retinal detachment (RRD) is a severe, sight-threating condition that may lead to permanent vision loss unless promptly managed. Recently, pars plana vitrectomy (PPV) has become increasingly popular as the first line of therapy for RRD repair because it enables superior visualization of the peripheral retina, release of vitreous traction around retinal breaks, and drainage of subretinal fluid. Achieving successful repair of RRD during PPV requires intraocular tamponading agents to maintain closure of all retinal breaks until sufficient chorioretinal adhesion develops. Postoperative head positioning is conventionally enforced for extended durations following surgery to maintain the retinal break–tamponade relationship and to minimize retinal shear stress. 1 -3 However, prolonged head posturing is troublesome, particularly for elderly patients and those with postural difficulties. Moreover, it may precipitate a variety of complications including pressure sores, 4 thromboembolic events, 5 and ulnar nerve palsies. 6 -8
Recent literature suggests the feasibility of brief positioning after RRD repair; however, there are limited data on the clinical results of RRD repair without postoperative positioning. Martínez-Castillo et al have reported successful repair of simple retinal detachment (RD) with inferior retinal breaks, when contact between the break and the tamponade may be transient and difficult to maintain. 9 -12 In their series of patients with simple inferior RD, Martínez-Castillo and colleagues demonstrated successful retinal reattachment even though none of the retinal breaks were tamponaded for more than 3 days. 9,10 Because the time required for an intraocular agent to tamponade retinal breaks to enable sufficient chorioretinal adhesion is not fully known, the need for strict postoperative positioning after RRD repair remains controversial. In this retrospective review of medical records, we evaluate the primary anatomical success rate of RRD cases of variable complexity repaired with no strict positioning after the surgery.
Methods
Study Design
We conducted a retrospective review of medical records of RRD repair surgical procedures performed by a single surgeon (R.T.) between January 2015 and September 2017. Data extracted included age, sex, lens status, number of retinal breaks, extent of detachment, location of the breaks, operative details, proliferative vitreoretinopathy (PVR) status, best-corrected visual acuity (BCVA), intraocular pressure (IOP), and postoperative complications. All pseudophakic eyes, including eyes that were rendered pseudophakic (ie, phakic eyes that were converted to pseudophakic at the time of surgery) that underwent RRD repair with no strict positioning instructions after the surgery, were included in the study.
In patients with phakic eyes, the silicone or gas bubble may come in contact with the crystalline lens during supine positioning, potentially constituting a mechanical barrier to diffusion of nutrients and oxygen that accelerates cataract formation. 13 In addition, contact of intraocular gas with the posterior lens surface early after surgery may induce posterior subcapsular changes and lens feathering, which may hinder the examination of the retina in the postoperative period. 14,15 Thus patients with phakic eyes were advised to avoid supine positioning. We therefore excluded all patients with phakic eyes who did not have combined PPV and phacoemulsification. In addition, patients who had less than 3 months of follow-up after surgery were excluded.
The primary outcome measure of the study was the primary anatomical success rate of RRD repair (ie, successful attachment of the retina with a single RRD repair operation) with nonrestricted postoperative positioning. To evaluate the primary anatomical success, postoperative follow-up data of at least 3 months following the surgery were collected. In cases that used silicone oil tamponade, follow-up extended to at least 3 months after the silicone oil was removed. Changes in BCVA, final reattachment rate, frequency of postoperative complications, and the rate of PVR formation were analyzed as secondary outcome measures.
Surgical Technique
A 23-gauge PPV (Constellation, Alcon Laboratories, Inc) was performed using wide-angle viewing systems (Resight, Carl Zeiss Meditec; and BIOM 5, Oculus Surgical, Inc). Phacoemulsification and intraocular lens (IOL) implantation were performed in conjunction with PPV in all phakic eyes. In addition, scleral buckle (41 band, 70 sleeve) was combined with PPV in selected cases with extensive peripheral retinal pathology and in monocular patients. Core vitrectomy with release of vitreous traction around retinal breaks and shaving of the peripheral vitreous was undertaken. Retinotomy was then created to drain the subretinal fluid during air-fluid exchange. Perfluorocarbon liquid was used in cases of giant retinal breaks, PVR, and retinectomy. Laser retinopexy around the retinal breaks and 360 degrees peripherally was performed. This was followed by exchanging the intraocular air with the tamponading agent.
Data Analysis
Snellen visual acuity measurements were converted to the logarithm of the minimum angle of resolution (logMAR) values. Visual acuities corresponding to counting fingers, hand movement, light perception, and no light perception were equated to 2.1, 2.4, 2.7, and 3.0 on the logMAR scale, respectively. 16 All statistical analyses and visualizations were generated using RStudio (http://www.rstudio.com/), an integrated development environment for R, with the additional Tidyverse (https://CRAN.R-project.org/package=tidyverse) package. Wilcoxon signed rank tests were used to evaluate the difference between paired preoperative and postoperative BCVA measurements. We conducted binary logistic regression to analyze factors predictive of failure of primary RD repair surgery. A P value threshold of .05 was selected to indicate statistical significance.
Results
Baseline Characteristics
Records of 182 patients who underwent RRD repair procedures between January 2015 and April 2017 were retrospectively reviewed. Data of 28 patients with insufficient follow-up and 32 patients with phakic eyes were excluded. Data of 122 eyes from 122 patients (85 male, 37 female) were included in the study. The mean (±SD) age of the patient population was 64 (±9) years. The mean (±SD) BCVA and IOP prior to surgical retinal reattachment were 1.2 (±1.0) logMAR (Snellen, 20/320) and 14.5 (±4.5) mm Hg, respectively. Fifty-five percent (68/122) of eyes were pseudophakic before the RD occurrence, 43% (52/122) were phakic eyes rendered pseudophakic at the time of RD surgery following combined cataract and PPV surgery, and 2% (2/122) of eyes were aphakic. The mean (±SD) number of retinal breaks was 2.5 (±2.4), and 3% (4/122) of patients presented with a giant retinal tear. Retinal breaks inferior to the midline (between the 4 o’clock and 8 o’clock positions) were found in 47% (57/122) of eyes. RD involved 2 to 3 quadrants in 66% (81/122) and 4 quadrants in 11% (13/122) of eyes. The macula was attached in 55% (67/122) of eyes, and PVR was deemed to be present in 21% (26/122) of eyes prior to surgical reattachment. Baseline characteristics of the study patients are presented in Table 1.
Table 1.
Baseline Characteristics of Total Patient Population.
Age, mean (±SD), y | 64 (±9) |
---|---|
Sex, no. (%) | |
|
85 (70) |
|
37 (30) |
Axial length, mean (±SD), mm | 25.9 (±2.0) |
Preoperative IOP, mean (±SD), mm Hg | 14.5 (±4.5) |
Preoperative BCVA, mean (±SD), logMAR | 1.2 (±1.0) (Snellen, 20/320) |
Lens status, no. (%) | |
|
52 (43) |
|
67 (55) |
|
2 (2) |
No. of breaks, mean (±SD) | 2.5 (±2.4) |
|
47 (39) |
|
62 (51) |
|
13 (11) |
Location of breaks, no. (%) | |
|
65 (53) |
|
57 (47) |
Macular status, no. (%) | |
|
67 (55) 55 (45) |
Extent of RD, no. (%) | |
|
28 (23) |
|
81 (66) |
|
13 (11) |
Preoperative PVR, no. (%) | |
|
9 (7) |
|
17 (14) |
Follow-up time, mean (±SD), mo | 15 (±12) |
Abbreviations: BCVA, best-corrected visual acuity; IOP, intraocular pressure; logMAR, logarithm of the minimum angle of resolution; RD, retinal detachment; PVR, proliferative vitreoretinopathy.
Functional and Anatomical Outcomes
Table 2 presents the operative details of patients who underwent RRD included in the present study: PPV alone was performed in 39% (47/122) of eyes and combined with phacoemulsification, scleral buckle, or both in 35% (43/122), 19% (23/122), and 7% (9/122) of eyes, respectively. Tamponade agents including sulfur hexafluoride gas, perfluoropropane gas, silicone oil, and Densiron-68 (Labtician Ophthalmics, Inc, Fluoron GmbH) tamponades were used in 9% (11/122), 62% (76/122), 19% (23/122), and 10% (12/112) of eyes, respectively.
Table 2.
Operative Details.
Type of operation, no. (%) | |
|
47 (39) |
|
43 (35) |
|
23 (19) |
|
9 (7) |
Type of tamponade, no. (%) | |
|
23 (19) |
|
12 (10) |
|
76 (62) |
|
11 (9) |
Laser retinopexy, no. (%) | |
|
70 (57) |
|
52 (43) |
Abbreviations: C3F8, perfluoropropane; SF6, sulfur hexafluoride.
Overall, we found that the primary anatomical success rate of RRD repair was 86% (105/122), with a mean follow-up of 15 months (median, 11 months; range, 3-87 months). Excluding complex cases with PVR grade C and giant retinal tears, the primary anatomical success rate improved to 91% (91/100). Table 3 outlines the surgical outcomes associated with RRD cases included in the present study. Retinal reattachment resulted in statistically significant improved mean (±SD) BCVA from 1.2 (±1.0) (Snellen, 20/320) to 0.76 (±0.78) (Snellen 20/125) logMAR (P < .001). Of the 45% (55/122) of eyes with macula-detached RRD, preoperative mean BCVA (1.80 [±0.75]) (Snellen, 20/1260) was improved to 0.97 (±0.80) logMAR (Snellen, 20/200) following RRD repair (P < .001). The remaining eyes with macula-attached RRD (67/122, 55%) did not show significant change between preoperative and postoperative mean BCVA (±SD) of 0.66 (±0.84) (Snellen, 20/100) and 0.59 (±0.74) (Snellen, 20/80) logMAR, respectively (P = .74).
Table 3.
Functional and Anatomical Outcomes of Reattachment Procedures Following Rhegmatogenous Retinal Detachment.
Postoperative BCVA, mean (± SD), logMAR | 0.76 (±0.78) |
Postoperative IOP, mean (± SD), mm Hg | 16.6 (±5.3) |
Rate of complications, no. (%) | |
|
20 (16) |
|
3 (2) |
|
16 (13) |
|
3 (2) |
|
4 (3) |
|
4 (3) |
|
2 (2) |
|
2 (2) |
|
1 (1) |
|
2 (2) |
|
1 (1) |
|
1 (1) |
|
1 (1) |
|
1 (1) |
|
1 (1) |
|
1 (1) |
|
2 (2) |
|
1 (1) |
|
1 (1) |
Primary anatomical success rate, % | 86 |
Final anatomical success rate, % | 98 |
Abbreviations: BCVA, best-corrected visual acuity; ERM, epiretinal membrane; IOL, intraocular lens; IOP, intraocular pressure; logMAR, logarithm of the minimum angle of resolution; PVR, proliferative vitreoretinopathy.
Table 3 lists the postoperative complications associated with RRD repair in the present study. The most common postoperative complication was epiretinal membrane (ERM) (20/122, 16%) followed by PVR (19/122, 15%). Less common complications included IOP spikes (4/122, 3%), cystoid macular edema (4/122, 3%), and IOL-related complications (3/122, 2%).
The characteristics associated with eyes that failed primary retinal reattachment (17/122, 14%) are summarized in Table 4. Of the 17 eyes with recurrent RDs, perfluoropropane gas was used in 53% (9/17) of eyes, and RD involved 2 to 3 quadrants in 53% (9/17) of eyes. Isolated inferior and superior breaks were present in 18% (3/17) and 29% (5/17) of eyes, respectively, whereas coexisting superior and inferior breaks were found in 53% (9/17) of eyes. Development of postoperative PVR was the reason for recurrence in 94% (16/17) of eyes, and reopening of the original retinal break owing to insufficient chorioretinal adhesion was observed in 1 case. The final reattachment rate was 98% (120/122); one patient had 2 failed operations and decided not to pursue further surgical procedures, the other had a funnel RD after the second surgery that was deemed inoperable. The remaining patients who had recurrent RD (15/17, 88%) remained stable for at least 3 months after dissipation or removal of the tamponading agent.
Table 4.
Characteristics of Eyes With Recurrence of Retinal Detachment After Primary Operation.
Age, mean (±SD), y | 67 (±9) |
---|---|
Sex, no. (%) | |
|
12 (71) |
|
5 (29) |
Initial BCVA, mean (±SD), logMAR | 1.2 (±1.0) (Snellen, 20/320) |
Primary operation, no. (%) | |
|
6 (35) |
|
6 (35) |
|
5 (29) |
Type of tamponade, no. (%) | |
|
5 (29) |
|
9 (53) |
|
3 (18) |
No. of breaks, mean (±SD) | 4.1 (±2.4) |
|
4 (24) |
|
9 (53) |
|
4 (24) |
Extent of RD, no. (%) | |
|
5 (29) |
|
9 (53) |
|
3 (18) |
Preexisting PVR, no. | |
|
1 (6) |
|
3 (18) |
Cause of recurrence | |
|
16 (94) |
|
1 (6) |
Second operation, no. (%) | |
|
10 (59) |
|
3 (18) |
Final BCVA, mean (±SD) | 1.2 (±0.8) (Snellen, 20/320) |
Abbreviations: BCVA, best-corrected visual acuity; C3F8, perfluoropropane; logMAR, logarithm of the minimum angle of resolution; PVR, proliferative vitreoretinopathy; RD, retinal detachment.
We conducted logistic regression analyses to evaluate factors predictive of failure of primary surgery. We included age, sex, location of breaks and RD, macular status, preoperative PVR, and type of surgery and tamponade used. Of these, age (odds ratio [OR] 1.1, P = .045) and coexisting superior and inferior breaks were found to be statistically significantly predictive of recurrence in our study (OR 7.2, P = .016). Table 5 lists the primary success rate of RRD with different surgical techniques and intraocular tamponades.
Table 5.
Success Rates of Rhegmatogenous Retinal Detachment Repair With Different Surgical Techniques and Intraocular Tamponade.
Superior Breaks Only, Recurrent/Overall (% Success) |
Inferior Breaks With or Without Coexisting Superior Breaks,
Recurrent/Overall (% Success) |
P (Fisher Exact Test) |
All Breaks, Recurrent/Overall (% Success) |
|
---|---|---|---|---|
Tamponade | ||||
|
3/49 (94) | 6/38 (84) | .17 | 9/87 (90) |
|
2/13 (85) | 3/10 (70) | .62 | 5/23 (78) |
|
0/3 (100) | 3/9 (67) | .51 | 3/12 (75) |
Surgical technique | ||||
|
3/29 (90) | 3/18 (83) | .66 | 6/47 (87) |
|
1/22 (95) | 5/21 (76) | .38 | 6/43 (86) |
|
1/14 (93) | 4/18 (78) | .35 | 5/32 (84) |
Overall | 4/65 (94) | 12/57 (79) | .02a | 17/122 (86) |
a P < .05.
Conclusions
Postoperative head positioning aims to optimize the interface between the tamponade bubble and retinal break as well as to reduce the possibility of head movements inducing retinal shearing stress. In this study, we evaluated a cohort of patients who underwent RRD repair with no strict head positioning after surgery. We found the rate of anatomical success following primary RRD repair surgery to be 86%. Jackson et al 17 reported a reattachment rate of 87% with a single procedure from a large sample of 3403 RRD cases in a United Kingdom National Database study. In other studies, primary reattachment rates have ranged from 77% to 96% (Table 6). The primary reattachment rate observed in the present study is therefore comparable to that published in prior studies in which postoperative head positioning has been enforced.
Table 6.
Comparison of Anatomical Success Rates Following Rhegmatogenous Retinal Detachment Repair in Studies of Varying Durations and Forms of Postoperative Positioning.
Study | Positioning | Primary Reattachment Rate (%) | Final Reattachment Rate (%) | No. | Inclusion Criteria | Exclusion Criteria |
---|---|---|---|---|---|---|
Thompson et al 18 | N/A | 77 | N/A | 728 | N/A | N/A |
Sharma et al 19 | Adjustable | 89 | 98 | 279 | Inferior breaks | GRT, retinal dialysis, trauma, PVR grade B or higher, retinoschisis, prior RRD repair |
Martínez-Castillo et al 10 | Prone (1 d) | 93 | 100 | 15 | Inferior breaks (4-8OC), pseudophakic | PVR grade B or worse, subretinal fibrosis or demarcation lines |
Martínez-Castillo et al 9 | Simple | 90 | 100 | 40 | Inferior breaks (4-8OC), pseudophakic | Asymptomatic RRD, retinoschisis, pediatric RRD, retinal dialysis, PVR grade C or higher, > 5 breaks, GRT, retinoschisis |
Jackson et al 17 | N/A | 87 | N/A | 3403 | N/A | N/A |
Chen et al 20 | Prone (7 d) | 90 | 100 | 29 | N/A | Other ocular disease, age < 18 y or > 80 y, prior RRD, GRT, trauma, PVR of grade C or higher, choroidal detachment, RRD due to MH in high-myopia eyes, symptoms > 4 wk, incomplete intraoperative drainage of subretinal fluid, hypotony at 1 d, F/U < 3 mo |
Adjustable (7 d) | 92 | 100 | 39 | |||
Martínez-Castillo et al 11 | Simple | 95 | 100 | 147 | Inferior breaks (4-8OC), pseudophakic, complete PVD | PVR grade C or higher, GRT, retinoschisis, dialysis |
Mikhail et al 21 | N/A | 91 | 98 | 109 | Age >18 y, DM 1 or 2, TRD or RRD and TRD | F/U < 3 mo, previous vitrectomy, other cause of PVR |
Lin et al 22 | Adjustable (1 wk-3 mo) | 93.3 | 95 | 403 | N/A | Trauma, prior RRD repair, < 3 mo follow up, incomplete information |
Keiko et al 23 | Prone (7 d) | 93.8 | 100 | 32 | N/A | GRT, PVR, atopic dermatitis, prior RRD repair |
Prone (1 d) + supine (7 d) | 93.3 | 100 | 30 | |||
Ajlan et al 24 | Prone (1 d) | 96 (1 mo); 84 (3 mo) |
N/A | 270 | PPV, 360-degree laser, C3F8, inferior breaks | History of previous RRD repair, scleral buckling, PVR, exudative RRD, retinoschisis, noncompliance, pregnant women, pediatrics |
Prone (7 d) | 93 (1 mo); 79 (3 mo) |
N/A | ||||
Shiraki et al 25 | Prone | 83 | 100 | 65 | N/A | History of surgery for any retinal disease, PVR of grade C or worse, GRT, myopic MH |
Adjustable | 96 | 100 | 77 | |||
Present study | Simple | 86 | 98 | 122 | N/A | Phakic patients, heavy silicone oil, F/U < 3 mo |
Abbreviations: 4-8OC, between 4 o’clock and 8 o’clock positions; C3F8, perfluoropropane; DM, diabetes mellitus; F/U, follow-up; GRT, giant retinal tear; MH, macular hole; N/A: not available; PVR, proliferative vitreoretinopathy; PPV, pars plana vitrectomy; PVD, posterior vitreous detachment; RRD, rhegmatogenous retinal detachment; TRD, tractional retinal detachment.
The potential benefits of brief or adjustable head positioning after PPV have been evaluated in previous studies. Shorter durations of restricted positioning regimens ameliorate some of the discomfort patients experience and consequently are associated with improved adherence to the positioning protocol. 26 The initial reattachment rate associated with adjustable positioning regimens may be comparable to that observed in cohorts of prone-positioned patients. 20,25 Adjustable positioning that is modified based on spatial characteristics of the retinal break is thought to promote better tamponade-break contact than does rigid prone positioning. 25 Similarly, the initial reattachment outcome associated with 1 day of postoperative positioning does not appear to differ from that associated with a longer 7-day period of posturing at 1- or 3-month follow-up. 24 Martínez-Castillo et al previously demonstrated 90% 9 and 95% 11 primary success with no postoperative head positioning in eyes with simple inferior RD. Our study demonstrates a slightly lower primary success rate (86%), perhaps because the present study included complex cases of RRD with grade C PVR and giant retinal tears that were excluded in the aforementioned reports. 9,11 Excluding complex cases from our study resulted in a primary anatomical success rate (91%) that is comparable to those studies that implemented brief or no postoperative head positioning following RRD repair.
Successful reattachment of the retina in the absence of positional restriction invokes important considerations regarding our understanding of the mechanism by which tamponade promotes retinal reattachment. The capacity of intraocular tamponade agents to reattach free retinal flaps is frequently attributed to the buoyant force exerted by the tamponading agent and the surface tension afforded by the bubble-retina interface, the latter of which is mathematically proven to be more significant in aiding chorioretinal adhesion. 27 In both cases, the contact of the bubble with a given retinal break is considered paramount to block the entry of intraocular fluid into the subretinal space. 27,28 Based on this theory, maintaining the break-tamponade interface through postoperative positioning would seem to be crucially important to mitigate the risk of redetachment following RRD repair.
Alternatively, some authors have hypothesized that the most significant means by which intraocular tamponade promotes recovery from RRD stems from its tendency to dissipate intraocular fluid currents that would otherwise cause retinal shear stress and potentially leakage of fluid into the subretinal space. 29,30 In a study by Angunawela et al, retinal shear stresses associated with normal head and saccadic eye movements were found to be insufficient to cause retinal break reopening when an intraocular gas bubble was present. 29 Thus, the capacity of an intraocular tamponade to maintain retinal adhesions may depend primarily on the mere presence of the tamponade within the eye, with less emphasis on the direct retinal break–tamponade relationship. Perhaps for this reason, the reattachment rates in the present study and prior series with brief or no postoperative positioning 9 -11 are high and comparable to those with restrictive head positioning.
Age and combined inferior and superior breaks were found to be predictive of recurrence in both simple and complex RDs in our study. Isolated inferior breaks were not found to be predictive of recurrence in the regression model. Although the significance of specific predictors varies among studies, Wong and colleagues found increased age to have an adverse effect on anatomic outcomes of primary RRD repair in a study of 1530 eyes. 31 This result is mirrored by that of Cheng et al, who found younger ages correlates with improved anatomical outcomes following primary RRD repair. 32 The tendency of anatomical outcomes to degrade with increasing age may be related to an age-dependent impairment of retinal repair mechanisms. 32
Retinal breaks that occur in the inferior quadrants were associated with an increased risk of surgical failure following RRD repair in several previous studies, 10,33 -35 foremost because they are less amenable to occlusion with intraocular tamponade. 12 This is particularly important when tamponades of low specific gravity are used. These tend to float in the aqueous, causing the tamponades to be insufficient for breaks that are inferior to the midline, and therefore postoperative positioning may be critical in these cases. This is in contrast to higher specific gravity tamponades such as Densiron, which provide a better tamponade to inferior breaks, potentially obviating the need for positioning. We found that in both gas- and Densiron-filled eyes, for PPV alone or combined with scleral buckle, the primary success in eyes with inferior breaks was lower (Table 5). Therefore, inferior breaks pose a therapeutic challenge regardless of whether the type of tamponade or surgical technique provided more support to these breaks. Possibly the presence of retinal defects that are inferiorly located is associated with a greater likelihood of retinal pigment epithelium precipitating inferiorly, thereby increasing the odds of PVR formation in that area. Another possibility is that inferior breaks are more susceptible to the traction induced by PVR, which frequently occurs inferiorly.
Conventionally, positioning is recommended for 5 to 7 days to maintain the tamponade–retinal break relationship until sufficient chorioretinal adhesion forms. 2,3 In our study, all inferior breaks except for 1 were closed at the 1-week follow-up visit, implying that a lack of positioning did not adversely influence the closure rate of these breaks. However, about 95% of recurrent detachments in this study were attributed to postoperative PVR rather than reopened breaks. Similarly, previous reports have noted that PVR is the most common cause of treatment failure following RRD repair. 36,37
Prone or adjustable positioning is thought to decrease the risk of anterior segment complications, including those relating to IOP or the IOL. Prone positioning aims to displace the tamponade bubble away from the anterior segment, obviating the risk of IOL displacement, pupillary block, and increased IOP. Additionally, prone positioning is useful in preventing inflammatory cells and cytokines from accumulating over the surface of the macula or inferiorly, thereby decreasing the risk of epimacular membranes and PVR inferiorly, respectively. Proliferation of ERM is reported to occur in up to 30% of cases following RRD repair in clinical studies, 38 -42 and the rate approaches 76% when retinae that have experienced RRD repair are evaluated post mortem. 43 In addition, PVR is estimated to occur in up to 19% of eyes after RD repair. In our study, the rate of IOL-related complications (2%), IOP spikes (3%), ERM (16%), and PVR (15%) were similar to prior studies that implemented prone positioning after surgery. 44 -47
Our results are limited by the variable surgical approaches and intraocular tamponades used among the patient cohort. To minimize confusion, we have reported the success rate with each surgical approach and type of tamponade included in the present study (Table 5). The lack of a control group undergoing RRD repair with strict postoperative positioning is another limitation of this study. In addition, the results may not directly extend to phakic eyes that undergo RRD repair without concomitant cataract surgery. In phakic eyes the gas fill may be less than in pseudophakic eyes, and this in turn may influence the degree of dissipation of intraocular fluid currents by the vitreous tamponade.
Despite these limitations, the present study has advantages. Our study comprised a relatively large series of RRDs that were repaired by a single surgeon, thereby preventing the potential confounding effect of intersurgeon differences. The present study included all pseudophakic eyes without excluding complex cases, and about half the series had inferior breaks. As such, our results are representative of real-world outcomes associated with RRD repair in pseudophakic eyes without postoperative positioning.
In conclusion, our results show that RRD repair with intraocular tamponade and without strict postoperative head positioning in pseudophakic eyes is associated with good anatomical outcomes. RD with combined superior and inferior breaks may have a lower success rate, and whether this is due to lack of postoperative positioning or the inherent increased risk of inferior breaks needs further evaluation in prospective, controlled studies.
Footnotes
Ethical Approval: Ethical approval was obtained from the Ottawa Health Science Network Research Ethics Board (Protocol number: 20170814-01H).
Statement of Informed Consent: The study was retrospective and consent was waived by the institutional review board.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Mohamed Kamel Soliman, MD
https://orcid.org/0000-0003-1671-8925
Harrish Nithianandan, MD
https://orcid.org/0000-0001-9122-658X
Alexander J. Lingley, MSc
https://orcid.org/0000-0002-6637-6364
References
- 1. Thompson J. Intraocular gases and techniques for air-fluid exchange. In: Peyman GA, Meffert SA, Conway MD, Peyman G, Conway M, eds. Vitreoretinal Surgical Techniques. 2nd ed. Oxon, UK: Informa Healthcare; 2007:538–549. [Google Scholar]
- 2. Gartry DS, Chignell AH, Franks WA, Wong D. Pars plana vitrectomy for the treatment of rhegmatogenous retinal detachment uncomplicated by advanced proliferative vitreoretinopathy. Br J Ophthalmol. 1993;77(4):199–203. doi:10.1136/bjo.77.4.199 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Heimann H, Bornfeld N, Friedrichs W, et al. Primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment. Graefes Arch Clin Exp Ophthalmol. 1996;234(9):561–568. doi:10.1007/BF00448800 [DOI] [PubMed] [Google Scholar]
- 4. Treister G, Wygnanski T. Pressure sore in a patient who underwent repair of a retinal tear with gas injection. Graefes Arch Clin Exp Ophthalmol. 1996;234(10):657–658. doi:10.1007/BF00185301 [DOI] [PubMed] [Google Scholar]
- 5. Au Eong KG, Beatty S, Thomas W, Sen V, Turner GS. Pulmonary embolism following head positioning for retinal reattachment surgery in a young patient with factor V leiden mutation. Arch Ophthalmol. 2000;118(9):1300–1301. https://jamanetwork.com/journals/jamaophthalmology/fullarticle/413553. Accessed November 25, 2019. [PubMed] [Google Scholar]
- 6. Ciulla TA, Frederick J, Kelly C, Amrein R. Postvitrectomy positioning complicated by ulnar nerve palsy. Am J Ophthalmol. 1996;122(5):739–740. doi:10.1016/S0002-9394(14)70500-8 [DOI] [PubMed] [Google Scholar]
- 7. Holekamp N, Meredith T, Landers M, et al. Ulnar neuropathy as a complication of macular hole surgery. Clin Sci. 1999;117(12):1607–1610. doi:10.1001/archopht.117.12.1607 [DOI] [PubMed] [Google Scholar]
- 8. Salam A, Harrington P, Raj A, Babar A. Bilateral ulnar nerve palsies: an unusual complication of posturing after macular hole surgery. Eye (Lond). 2004;18(1):95–97. doi:10.1038/sj.eye.6700515 [DOI] [PubMed] [Google Scholar]
- 9. Martínez-Castillo V, Boixadera A, Verdugo A, García-Arumí J. Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position. Ophthalmology. 2005;112(7):1222–1226. doi:10.1016/j.ophtha.2004.12.046 [DOI] [PubMed] [Google Scholar]
- 10. Martínez-Castillo V, Verdugo A, Boixadera A, García-Arumí J, Corcóstegui B. Management of inferior breaks in pseudophakic rhegmatogenous retinal detachment with pars plana vitrectomy and air. Arch Ophthalmol. 2005;123(8):1078–1081. doi:10.1001/archopht.123.8.1078 [DOI] [PubMed] [Google Scholar]
- 11. Martínez-Castillo VJ, García-Arumí J, Boixadera A. Pars plana vitrectomy alone for the management of pseudophakic rhegmatogenous retinal detachment with only inferior breaks. Ophthalmology. 2016;123(7):1563–1569. doi:10.1016/j.ophtha.2016.03.032 [DOI] [PubMed] [Google Scholar]
- 12. Fawcett I, Williams R, Wong D. Contact angles of substances used for internal tamponade in retinal detachment surgery. Graefes Arch Clin Exp Ophthalmol. 1994;232(7):438–444. doi:10.1007/BF00186587 [DOI] [PubMed] [Google Scholar]
- 13. Krzystolik MG, D’Amico DJ. Complications of intraocular tamponade: silicone oil versus intraocular gas. Int Ophthalmol Clin. 2000;40(1):187–200. doi:10.1097/00004397-200040010-00018 [DOI] [PubMed] [Google Scholar]
- 14. Sabates WI, Abrams GW, Swanson DE, Norton EW. The use of intraocular gases: the results of sulfur hexafluoride gas in retinal detachment surgery. Ophthalmology. 1981;88(5):447–454. doi:10.1016/S0161-6420(81)35005-2 [PubMed] [Google Scholar]
- 15. Mohamed S, Lai TYY. Intraocular gas in vitreoretinal surgery. Hong Kong J Ophthalmol. 2010;14(1):8–13. http://www.cohk.org.hk/download/V14N1-p8.pdf. Accessed November 9, 2019. [Google Scholar]
- 16. Day AC, Donachie PH, Sparrow JM, Johnston RL; Royal College of Ophthalmologists’ National Ophthalmology Database. The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications. Eye (Lond). 2015;29(4):552–560. doi:10.1038/eye.2015.3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Jackson TL, Donachie PH, Sallam A, Sparrow JM, Johnston RL. United Kingdom National Ophthalmology Database study of vitreoretinal surgery: report 3, retinal detachment. Ophthalmology. 2014;121(3):643–648. doi:10.1016/j.ophtha.2013.07.015 [DOI] [PubMed] [Google Scholar]
- 18. Thompson JA, Snead MP, Billington BM, Barrie T, Thompson JR, Sparrow JM. National audit of the outcome of primary surgery for rhegmatogenous retinal detachment, II: clinical outcomes. Eye. 2002;16(6):771–777. doi:10.1038/sj.eye.6700325 [DOI] [PubMed] [Google Scholar]
- 19. Sharma A, Grigoropoulos V, Williamson TH. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol. 2004;88(11):1372–1375. doi:10.1136/bjo.2003.041350 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Chen X, Yan Y, Hong L, Zhu L. A comparison of strict face-down positioning with adjustable positioning after pars plana vitrectomy and gas tamponade for rhegmatogenous retinal detachment. Retina. 2015;35(5):892–898. doi:10.1097/IAE.0000000000000413 [DOI] [PubMed] [Google Scholar]
- 21. Mikhail M, Ali-Ridha A, Chorfi S, Kapusta MA. Long-term outcomes of sutureless 25-G+ pars-plana vitrectomy for the management of diabetic tractional retinal detachment. Graefe’s Arch Clin Exp Ophthalmol. 2017;255(2):255–261. doi:10.1007/s00417-016-3442-7 [DOI] [PubMed] [Google Scholar]
- 22. Lin Z, Sun JT, Wu RH, Moonasar N, Zhou YH. The Safety and Efficacy of Adjustable Postoperative Position after Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment. J Ophthalmol. 2017;2017:5760173. doi:10.1155/2017/5760173 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Keiko O, Hisanori I, Akiko M, Makoto N. Impact of postoperative positioning on the outcome of pars plana vitrectomy with gas tamponade for primary rhegmatogenous retinal detachment: comparison between supine and prone positioning. Acta Ophthalmol. 2017;96(2):e189–194. doi:10.1111/aos.13482 [DOI] [PubMed] [Google Scholar]
- 24. Ajlan R, Isenberg J, Cordahi G, Duval R, Olivier S, Rezende F. Primary rhegmatogenous retinal detachment with inferior retinal breaks postoperative prone positioning results: 1 day versus 7 days. Int J Retina Vitreous. 2017;3:47. doi:10.1186/s40942-017-0100-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Shiraki N, Sakimoto S, Sakaguchi H, Nishida K, Nishida K, Kamei M. Vitrectomy without prone positioning for rhegmatogenous retinal detachments in eyes with inferior retinal breaks. PLoS One. 2018;13(1):e0191531. doi:10.1371/journal.pone.0191531 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Suzuki K, Shimada Y, Seno Y, Mizuguchi T, Tanikawa A, Horiguchi M. Adherence to the face-down positioning after vitrectomy and gas tamponade: a time series analysis. BMC Res Notes. 2018;11(1):142. doi:10.1186/s13104-018-3257-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Foster WJ, Chou T. Physical mechanisms of gas and perfluoron retinopexy and sub-retinal fluid displacement. Phys Med and Biol. 2004;49(13):2989–2997. doi:10.1088/0031-9155/49/13/015 [DOI] [PubMed] [Google Scholar]
- 28. Gupta D. Rethinking surface tension and buoyancy. Arch Ophthalmol. 2011;129(8):1109–1110. doi:10.1001/archophthalmol.2011.176 [DOI] [PubMed] [Google Scholar]
- 29. Angunawela RI, Azarbadegan A, Aylward GW, Eames I. Intraocular fluid dynamics and retinal shear stress after vitrectomy and gas tamponade. Invest Ophthalmol Vis Sci. 2011;52(10):7046–7051. doi:10.1167/iovs.10-6872 [DOI] [PubMed] [Google Scholar]
- 30. Kuhn F, Aylward B. Rhegmatogenous retinal detachment: a reappraisal of its pathophysiology and treatment. Ophthalmic Res. 2014;51(1):15–31. doi:10.1159/000355077 [DOI] [PubMed] [Google Scholar]
- 31. Wong CW, Wong WL, Yeo IYS, et al. Trends and factors related to outcomes for primary rhegmatogenous retinal detachment surgery in a large Asian tertiary eye center. Retina. 2014;34(4):684–692. doi:10.1097/IAE.0b013e3182a48900 [DOI] [PubMed] [Google Scholar]
- 32. Cheng SF, Yang CH, Lee CH, et al. Anatomical and functional outcome of surgery of primary rhegmatogenous retinal detachment in high myopic eyes. Eye (Lond). 2008;22(1):70–76. doi:10.1038/sj.eye.6702527 [DOI] [PubMed] [Google Scholar]
- 33. Goto T, Nakagomi T, Iijima H. A comparison of the anatomic successes of primary vitrectomy for rhegmatogenous retinal detachment with superior and inferior breaks. Acta Ophthalmol. 2013;91(6):552–556. doi:10.1111/j.1755-3768.2012.02455.x [DOI] [PubMed] [Google Scholar]
- 34. Heimann H, Zou X, Jandeck C, et al. Primary vitrectomy for rhegmatogenous retinal detachment: an analysis of 512 cases. Graefes Arch Clin Exp Ophthalmol. 2006;244(1):69–78. doi:10.1007/s00417-005-0026-3 [DOI] [PubMed] [Google Scholar]
- 35. Sharma YR, Karunanithi S, Azad RV, et al. Functional and anatomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand. 2005;83(3):293–297. doi:10.1111/j.1600-0420.2005.00461.x [DOI] [PubMed] [Google Scholar]
- 36. Roldán-Pallarés M, Musa A, Hernandez-Montero J, Rollin R, Bravo-Llatas C, Fernández-Durango R. Retinal detachment and proliferative vitreoretinopathy: ophthalmic artery blood velocities, intraocular pressure, and endothelin-1. Retina. 2008;28(1):111–124. doi:10.1097/IAE.0b013e31809ffad0 [DOI] [PubMed] [Google Scholar]
- 37. Thompson JT. Negative results matter: why can’t we improve the treatment of proliferative vitreoretinopathy? Ophthalmology. 2017;124(6):753–754. doi:10.1016/j.ophtha.2017.02.020 [DOI] [PubMed] [Google Scholar]
- 38. Lobes LA, Burton TC. The incidence of macular pucker after retinal detachment surgery. Am J Ophthalmol. 1978;85(1):72–77. doi:10.1016/s0002-9394(14)76668-1 [DOI] [PubMed] [Google Scholar]
- 39. Tanenbaum HL, Schepens CL, Elzeneiny I, Freeman HM. Macular pucker following retinal detachment surgery. Arch Ophthalmol. 1970;83(3):286–293. doi:10.1001/archopht.1970.00990030288004 [DOI] [PubMed] [Google Scholar]
- 40. de Bustros S, Rice TA, Michels RG, Thompson JT, Marcus S, Glaser BM. Vitrectomy for macular pucker: use after treatment of retinal tears or retinal detachment. Arch Ophthalmol. 1988;106(6):758–760. doi:10.1001/archopht.1988.01060130828032 [DOI] [PubMed] [Google Scholar]
- 41. Martínez-Castillo V, Boixadera A, Distéfano L, Zapata M, García-Arumí J. Epiretinal membrane after pars plana vitrectomy for primary pseudophakic or aphakic rhegmatogenous retinal detachment incidence and outcomes. Retina. 2012;32(7):1350–1355. doi:10.1097/IAE.0b013e318242b965 [DOI] [PubMed] [Google Scholar]
- 42. Cho EH, Ku HC, Il W, Lee EK. Residual vitreous cortex at the fovea during vitrectomy for primary rhegmatogenous retinal detachment repair. Retina. 2018;38(8):1549–1555. doi:10.1097/IAE.0000000000001734 [DOI] [PubMed] [Google Scholar]
- 43. Wilson DJ, Green WR. Histopathologic study of the effect of retinal detachment surgery on 49 eyes obtained post mortem. Am J Ophthalmol. 1987;103:167–179. doi:10.1016/s0002-9394(14)74222-9 [DOI] [PubMed] [Google Scholar]
- 44. The SPR Study Group. View 2: the case for primary vitrectomy. Br J Ophthalmol. 2003;87:784–787. doi:10.1136/bjo.87.6.784 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45. Girard P, Mimoun G, Karpouzas I, Montefiore G. Clinical risk factors for proliferative vitreoretinopathy after retinal detachment surgery. Retina. 1994;14(5):417–424. doi:10.1097/00006982-199414050-00005 [DOI] [PubMed] [Google Scholar]
- 46. Lv Z, Li Y, Wu Y, Qu Y. Surgical complications of primary rhegmatogenous retinal detachment: a meta-analysis. PLoS One. 2015;10(3):e0116493. doi:10.1371/journal.pone.0116493 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47. Schaal S, Sherman MP, Barr CC, Kaplan HJ. Primary retinal detachment repair: comparison of 1-year outcomes of four surgical techniques. Retina. 2011;31(8):1500–1504. doi:10.1097/IAE.0b013e31820d3f55 [DOI] [PubMed] [Google Scholar]