Reducing the development of retinal detachments (RDs) after pars plana vitrectomy (PPV) to treat a variety of vitreoretinal disorders is an ongoing, ever-changing endeavor. The evolution of vitrectomy technology (25- and 27-gauge, high cutting rates, advanced fluidics, and endolaser photocoagulation) has led to additional treatment options and opportunities for improved patient outcomes.

Currently, many surgeons prefer to perform PPV over scleral buckle (SB) procedures for RDs.1 Others advocate for using a SB or combining SB and PPV.2 However, studies suggest that PPV/SB may not be efficacious.3-5 In this article, we discuss risk factors for post-PPV RD and address the growing controversy regarding the best treatment approach for patients at high risk for this postoperative complication.

RD RISK FACTORS

There are several factors that lead to the development of postoperative RD. Eyes at the highest risk of developing post-PPV RD are those in which a posterior vitreous detachment (PVD) is created during vitrectomy. This can include macular hole repair, non-PVD associated detachments (young myopes with round holes), vitreomacular traction, vitreomacular schisis, and inherited collagenopathies, such as Stickler syndrome and Wagner syndrome.6-8 The interaction between residual vitreous and the air, gas, or silicone bubbles may lead to new inferior retinal breaks.9 The interaction with the superior aspect of perfluorocarbon liquid in cases of medium-term PFO may cause new superior retinal breaks.10

Eyes with a low risk of postoperative RD are those in which a prior PVD has occurred without RD, retinal break, or lattice degeneration; eyes with diabetic tractional RDs; and post-PPV eyes with sufficient vitreous removal accompanied by 360° scleral depression.

TO BUCKLE OR NOT TO BUCKLE

Some surgeons suggest using an SB or combined SB/PPV at the time of RD surgery.2 Advocates of PPV/SB believe that the buckle reduces postoperative PPV RD compared with vitrectomy alone.2 However, an argument can be made that it is the degree of retinopexy that provides the benefit.

Other studies have compared SB, PPV, and PPV/SB, and the data suggest that combining PPV with SB doesn’t add any benefit. For example, in a meta-analysis comparing PPV with PPV/SB, there is similar single-surgery anatomic success between the approaches.3 Further, a Cochrane review comparing SBs with PPV found low-certainty evidence favoring PPV.4 Additionally, a large meta-analysis comparing PPV, SB, and pneumatic retinopexy found similar outcomes with PPV and SB with no added benefit of combined PPV/SB.5 In Brazitikos et al, a series of vitrectomies without SB produced better RD outcomes than the PRO series of PPV outcomes, which included SBs.11,12

SBs are associated with 2.75 D of induced myopia, diplopia, infection, and extrusion.10,13,14 The practical arguments for PPV alone are that there is no induced myopia or strabismus, and there are fewer ocular surface disorders due to minimal conjunctival and epithelial disruption.15,16 Further, SBs induce significant tenons and conjunctival scarring, thereby creating challenges for and limiting the efficacy of potential future glaucoma filtering procedures.17

LASERS

The use of prophylactic 360° laser retinopexy versus localized laser retinopexy around identified retinal breaks to reduce the risk of post-PPV RD is an area of debate.18 A large series in Japan noted a significant risk reduction of post-PPV RD with 360° laser retinopexy at the vitreous base.19 Additionally, there is a threefold reduction in the incidence of postoperative RD with the use of prophylactic 360° laser retinopexy.20,21 In particular, prophylactic extended vitreous base laser significantly reduces the risk of RD in patients with Stickler syndrome.22 Thus, adjunct or prophylactic 360° laser retinopexy appears to be advantageous in the prevention of postoperative RD.

Higher laser power has the potential to create retinal breaks at the laser edges, formation of proliferative vitreoretinopathy, and pupillary abnormalities due to ciliary nerve damage. However, the application of a low-intensity, nearly confluent laser to the vitreous base should reduce the risks.

Intraoperatively, endolaser photocoagulation is preferred to a laser indirect ophthalmoscope, as it improves surgeon ergonomics and prevents direct iris damage.

KEY TAKEAWAYS

SB combined with PPV may not be an efficacious approach to reduce the risk of post-vitrectomy RD.

Prophylactic 360° low-intensity endolaser photocoagulation at the vitreous base reduces postoperative RD and should be used in high-risk cases.

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