Rhegmatogenous retinal detachment (RRD) can be surgically treated with scleral buckling (SB), pars plana vitrectomy (PPV), or a combination of the 2 procedures. Responses to the American Society of Retina Surgeons' Preferences and Trends Survey suggest a declining use of SB over the past decade. The biggest reason for this trend is advances in the techniques and instrumentation used to repair RRDs with primary PPV. Although this trend may be justified in general by similar success rates reported with primary PPV and SB, not all RRD cases are the same.

With decreasing utilization of SB, an important question arises: Are there certain situations in which the addition of SB provides superior outcomes in RRD repair? In recent years, a number of randomized controlled trials and retrospective reviews have evaluated SB with or without PPV versus PPV alone for patients with RRD.1­-9 In general, these studies have found no significant differences in outcomes. However, the majority of these trials and reviews have focused on simple to moderately complex cases and excluded patients with high-risk characteristics.

HIGH-RISK REPAIR

The most common cause of failure of surgical repair in RRD is proliferative vitreoretinopathy (PVR), a complex process involving cellular proliferation, migration, and inflammation (Figures 1 and 2). We hypothesized that there may be a role for the addition of SB in eyes at high risk for PVR and primary surgical failure. In a recently published study, our group evaluated surgical outcomes in eyes with high-risk RRDs.10

We initiated a retrospective study that included 678 patients with RRD treated with a combination of PPV and SB or PPV alone between April 1, 2010, and August 1, 2012, at a large retina practice. After reviewing published literature of risk factors for PVR, we classified patients as being at high risk for failure if they had a RRD in 2 or more quadrants, retinal tears greater than 1-clock hour, preoperative PVR grade B or higher, or vitreous hemorrhage obscuring 5 or more clock hours of central or peripheral retinal RRD in 2 or more quadrants.11-14 Patients were excluded if they lacked high-risk features, had less than 3 months follow-up, were treated with SB without PPV, or were previously treated with SB or PPV in the study eye.

Figure 1. Image of grade D proliferative vitreoretinopathy.

Patients underwent a standard 3-port 23-gauge PPV using a noncontact wide-angle viewing system. Endolaser photocoagulation was applied either around the retinal tear or around 360° to the vitreous base. In all cases, patients received nonexpansile C3F8, SF6, or silicone oil for tamponade. Patients in the SB group received a 360° encircling band secured with a Watzke sleeve.

Of 678 patients reviewed, 65 (9.6%) qualified as high-risk and were included in the study. A group of 13 surgeons performed PPV-SB in 36 patients and PPV alone in 29 patients. Baseline demographics including age, lens status, baseline visual acuity, and high-risk features did not differ between the surgical groups.

The primary outcome for our study was single surgery anatomic success, defined as 1 operation to anatomically reattach 100% of the retina for at least 3 months. The overall success rate regardless of surgical procedure for the 65 high-risk patients was 63.1%, which is consistent with previously reported rates of high-risk cases. We found that the addition of SB was associated with significantly higher success rates compared with PPV alone. For patients treated with PPV-SB, surgical success was 75.0% (27 of 36) compared with 48.3% (14 of 29) for patients treated with PPV alone, giving an odds ratio of 3.24 (95% CI 1.12-9.17; P = .029).

BASELINE CHARACTERISTICS

Among baseline characteristics evaluated, 1 factor significantly affected surgical success: age. For patients 65 years of age and younger, PPV-SB had a significantly higher success rate compared with PPV alone (84.6% for PPV-SB vs 46.2% for PPV), with an odds ratio of 6.42 (95% CI 1.40-29.5; P = .017). For patients older than 65 years, there was no difference in anatomic outcomes between the surgical approaches. Interpretation of these results suggests that, as the vitreous gel becomes more syneretic, the benefit of SB declines. This may provide a useful guideline as surgeons plan repairs for high-risk patients.

Figure 2. Fundus photograph montage of grade C proliferative vitreoretinopathy.

Lens status has been considered to play an important role in surgical planning for PPVs based on previously reported studies. One randomized trial, which excluded patients with high-risk characteristics including preoperative PVR and tears in more than 2 quadrants, found that SB resulted in better functional success in phakic patients while PPV achieved better anatomic outcomes in pseudophakic patients.9 Another study found that SB had superior outcomes compared with PPV alone in phakic eyes but that outcomes were no different in pseudophakic eyes.15

In contrast, our study found that lens status did not have an impact on surgical outcomes in this high-risk cohort. For both phakic and pseudophakic patients, the addition of SB was associated with superior surgical success compared with PPV alone, but the differences were not statistically significant.

SHOULD SURGICAL APPROACH DIFFER?

Surgical approaches for low to moderate complexity RRDs have been well studied, and success rates have generally been similar among the procedures studied. However, less is known concerning comparative surgical outcomes in patients at high-risk for failure. Our study was the first to specifically evaluate surgical outcomes in patients at high risk for PVR, and we found that the addition of SB resulted in significantly higher success rates.

Success rates of surgical repair of RRD in low- and medium-risk eyes have ranged from 68% to 99%.2,3,5,6,8,9,15-18 The cohort of high-risk patients in our study—the roughly 10% of patients at highest risk for failure—had a single-surgery success rate of 63.1%. The primary reason for this lower success rate was, as expected, a substantially higher rate of postoperative PVR: 3% to 12% in previous studies of low- and medium-risk patients compared with our rate of 23.1%.

A number of randomized controlled trials have explored surgical management for patients with uncomplicated RRD with variable conclusions. Some randomized trials found no difference in single-surgery anatomic success between SB alone versus PPV.2,6,19,20 One study found that PPV had significantly higher attachment rates than SB alone.3 However, in all of these randomized trials, eyes with PVR grade C or D were excluded, and some studies excluded patients with vitreous hemorrhage or large tears, all of which were inclusion criteria for our study of high-risk eyes. Additionally, we compared the combination PPV-SB to PPV alone, while the vast majority of published trials have compared SB alone to PPV alone.

CONCLUSION

Given the declining use of SB for primary repair of RRD, the results of our recent study are notable. Improvement of instrumentation for PPV surgery, shorter operating times, and decreased need for suturing have all contributed to increased preference of PPV over SB. While a surgeon's comfort with a particular operation may also guide his or her choice, procedures should be selected to meet the needs of the individual patient and should be based on the strength of clinical evidence. Our study suggests that, when a patient presents with RRD at high risk for failure to reattach, and the patient is 65 years or younger, the surgeon should consider use of a SB in addition to PPV to increase the likelihood of successful repair. n

Richard Kaiser, MD, is an associate professor at Thomas Jefferson University and the codirector of the retina fellowship at Wills Eye Hospital in Philadelphia, Pennsylvania. Dr. Kaiser may be reached at richardskaiserMD@gmail.com.

Philip Storey, MD, MPH, completed a research fellowship in the retina department of Wills Eye Hospital and is now a resident at the University of Southern California in Los Angeles, California. Dr. Storey may be reached at storey.p@gmail.com.

No conflicting relationship exists for either author.

1. Arya AV, Emerson JW, Engelbert M, et al. Surgical management of pseudophakic retinal detachments: a meta-analysis. Ophthalmology. 2006;113:1724-1733.

2. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment: six-month follow-up results of a single operation--report no. 1. Ophthalmology. 2005;112:1421-1429.

3. Brazitikos PD, Androudi S, Christen WG, et al. Primary pars plana vitrectomy versus scleral buckle surgery for the treatment of pseudophakic retinal detachment: a randomized clinical trial. Retina. 2005;25:957-964.

4. Gartry DS, Chignell AH, Franks WA, et al. Pars plana vitrectomy for the treatment of rhegmatogenous retinal detachment uncomplicated by advanced proliferative vitreoretinopathy. Br J Ophthalmol. 1993;77:199-203.

5. Weichel ED, Martidis A, Fineman MS, et al. Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment. Ophthalmology. 2006;113:2033-2040.

6. 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;83:293-297.

7. Schaal S, Sherman MP, Barr CC, et al. Primary retinal detachment repair: comparison of 1-year outcomes of four surgical techniques. Retina. 2011;31:1500-1504.

8. Kinori M, Moisseiev E, Shoshany N, et al. Comparison of pars plana vitrectomy with and without scleral buckle for the repair of primary rhegmatogenous retinal detachment. Am J Ophthalmol. 2011;152:291-297 e292.

9. Heimann H, Bartz-Schmidt KU, Bornfeld N, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. Ophthalmology. 2007;114:2142-2154.

10. Storey P, Alshareef R, Khuthaila M, et al. Pars plana vitrectomy and scleral buckle versus pars plana vitrectomy alone for patients with rhegmatogenous retinal detachment at high risk for proliferative vitreoretinopathy. Retina. 2014;34:1945-1951.

11. Girard P, Mimoun G, Karpouzas I, et al. Clinical risk factors for proliferative vitreoretinopathy after retinal detachment surgery. Retina. 1994;14:417-424.

12. Nagasaki H, Shinagawa K, Mochizuki M. Risk factors for proliferative vitreoretinopathy. Prog Retin Eye Res. 1998;17:77-98.

13. Kon CH, Asaria RH, Occleston NL, et al. Risk factors for proliferative vitreoretinopathy after primary vitrectomy: a prospective study. Br J Ophthalmol. 2000;84:506-511.

14. Cowley M, Conway BP, Campochiaro PA, et al. Clinical risk factors for proliferative vitreoretinopathy. Arch Ophthalmol. 1989;107:1147-1151.

15. Adelman RA, Parnes AJ, Ducournau D. Strategy for the management of uncomplicated retinal detachments: the European Vitreo-Retinal Society Retinal Detachment Study Report 1. Ophthalmology. 2013;120:1804-1808.

16. Pastor JC, Fernandez I, Rodriguez de la Rua E, et al. Surgical outcomes for primary rhegmatogenous retinal detachments in phakic and pseudophakic patients: the Retina 1 Project--report 2. Br J Ophthalmol. 2008;92:378-382.

17. Miki D, Hida T, Hotta K, et al. Comparison of scleral buckling and vitrectomy for retinal detachment resulting from flap tears in superior quadrants. Jpn J Ophthalmol. 2001;45:187-191.

18. Afrashi F, Erakgun T, Akkin C, et al. Conventional buckling surgery or primary vitrectomy with silicone oil tamponade in rhegmatogenous retinal detachment with multiple breaks. Graefes Arch Clin Exp Ophthalmol. 2004;242:295-300.

19. Sun Q, Sun T, Xu Y, et al. Primary vitrectomy versus scleral buckling for the treatment of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled clinical trials. Curr Eye Res. 2012;37:492-499.

20. Soni C, Hainsworth DP, Almony A. Surgical management of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled trials. Ophthalmology. 2013;120:1440-1447.