APAO 2017 - Retinal detachment lecture - Pars Plana vitrectomy
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Lecture for retinal detachment presented during the 2017 APAO in Singapore
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APAO 2017 - Retinal detachment lecture - Pars Plana vitrectomy
- 1. PARS PLANA VITRECTOMY WITHOUT ENCIRCLING BAND FOR RETINAL DETACHMENT REPAIR NARCISO F. ATIENZA, JR. MD MBA FPCS, FPAO CARDINAL SANTOS MEDICAL CENTER ST. LUKES MEDICAL CENTER LEGASPI EYE CENTER BUDDHIST TZU CHI CHARITY EYE CENTER
- 2. DISCLOSURES • Allergan • Bausch and Lomb Surgicals • Novartis
- 3. QUESTIONS • Is pars plans vitrectomy surgery alone enough for retinal detachment repair? • Does doing an additional step change the final anatomic and visual outcome of surgery?
- 6. CURRENT TREND FOR NON COMPLICATED RETINAL DETACHMENTS (PHAKIC / PSEUDOPHAKIC) • PARS PLANA VITRECTOMY +/- ENCIRCLING BAND • SMALLER GAUGE VITRECTOMY 23G / 25G / 27G • PERFLUOROCARBON LIQUID • ENDOLASER / CRYOPEXY • GAS TAMPONADE (SF6, C2F6, C3F8) • SILICONE OIL (5000 CS, 1000 CS, FLUORINATED SILICONE OIL)
- 8. WHY PLACE A BAND/BUCKLE • Additional support for the vitreous base, especially in pseudophakic patients / breaks on inferior meridian. • Lessens the extent of residual vitreous traction on the retinal breaks, especially inferior located breaks
- 9. PARS PLANA VITRECTOMY ALONE IS ENOUGH • Vitrectomy is usually enough to allow adequate removal of peripheral vitreous during retinal detachment surgery • Extensive cerclage using endophotocoagulation allows support of the vitreous base
- 10. WHY PLACING A BAND / BUCKLE IS NOT NEEDED • Anatomic / functional success rates are similar. • Placing a band induces change in axial length leading to changes in refraction. • Intra-operative / post-operative problems when placing a buckle/band • Traumatic disinsertion of an extra-ocular muscle • Diplopia • Anterior segment ischemia • Cost is higher in adding a band
- 11. • Pars plana vitrectomy surgery for retinal detachment • 20 phakic eyes • 2 aphakic eyes • 7 pseudophakic eyes • The reattachment rate after one operation was 79% (23 of 29 eyes); after two operations this increased to 93% (27 of 29 eyes). Escoffery RF, Olk RJ, Grand MG, Boniuk I Vitrectomy without scleral buckling for primary rhegmatogenous retinal detachment. .Am J Ophthalmol. 1985 Mar 15;99(3):275-81.
- 12. PROSPECTIVE • Vitrectomy is an effective initial treatment for PsRD, whereas the benefit of an additional encircling buckling procedure is questionable. • re-attachment rate was 97% in the vitrectomy alone, 92% in the vitrectomy plus buckle group. Stangos AN, Petropoulos IK, Brozou CG, Kapetanios AD, Whatham A, Pournaras CJ. Pars-plana vitrectomy alone vs vitrectomy with scleral buckling for primary rhegmatogenous pseudophakic retinal detachment. Am J Ophthalmol. 2004 Dec;138(6):952-8.
- 13. RETROSPECTIVE • Primary PPV and PPV/SB seem to have similar efficacy in the repair of a matched group of patients with primary noncomplex pseudophakic retinal detachment. There was no statistically significant difference in complication rate between the 2 groups. • Primary PPV group - 63 of 68 eyes (92.6%) • Primary PPV/SB group - 79 of 84 eyes (94.0%) Weichel ED, Martidis A, Fineman MS, McNamara JA, Park CH, Vander JF, Ho AC, Brown GC. Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment. Ophthalmology. 2006 Nov;113(11):2033-40.
- 14. • Vitrectomy with gas is efficient in retinal detachment. Additional encircling band does not significantly reduce risk for any second procedure to reattach retina in 20 G vitrectomy. • PPV alone - 73.5% • PPV + encircling band - 79% • Small gauge trans conjunctival vitrectomy is not inferior to conventional 20 G technique • PPV (23/25G) - 87.7% • PPV (20 G) - 78.7% Walter P. Hellmich M. Vitrectomy with and without encircling band for pseudophakic retinal detachment: VIPER Study Report No.2 BJO; 0, 1-7
- 15. PARS PLANA VITRECTOMY ONLY SERIES • 39 of the 48 patients (81.3%) with inferior breaks were treated successfully with one operation. • 41 of 48 patients (85.4%) control patients achieved primary success. • The final success rate was 95.8% in both groups. Sharma A, Grigoropoulos V, Williamson T. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol 2004;88:1372–1375.
- 16. • Vitrectomy and gas without the application of a scleral buckle may be used to safely treat inferior break retinal detachments. • SOSR - 89% in group A (PPV, gas) versus 73% in group B (PPV, SB, gas) • Final Success rate - 95% in group A and 93% in group B Wickham L, Connor M, Aylward GW. Vitrectomy and gas for inferior break retinal detachments: are the results comparable to vitrectomy, gas, and scleral buckle? Br J Ophthalmol. 2004 Nov;88(11):1376-9.
- 17. • The EVRS RD study is a statistical study based on 7678 cases concerning only primary procedures and PVR stages 0, A, B and C1. • The goal of this study was to highlight the variables that affect the final surgical outcome.
- 18. PROCEDURE DONE
- 19. • Addition of encircling band element or buckle • PVR 0 - A: Equatorial breaks and normal tears - higher rate of complications compared to those who had vitrectomy alone
- 20. • Addition of encircling band element or buckle • PVR 0 - A: Equatorial breaks and normal tears - less complications / failure in vitrectomy alone
- 21. SUMMARY OF THE EVRS RD STUDY • Majority of members do vitrectomy surgery for retinal detachment regardless of phakic status • Addition of a scleral buckle/band in vitrectomy surgery is associated with higher complication rate, and no improvement in vitrectomy outcomes. • Surgeon preference on putting a band where the case maybe difficult, hence higher rate of failure, and less favorable outcome.
- 23. DONEC QUIS NUNC
- 24. VITRECTOMY IN PHAKIC RETINAL DETACHMENTS• Pars plana vitrectomy as a primary procedure is gaining more popularity. • Scleral buckle alone is still part of the armamentarium in a significant number of VR surgeons. “The lost art” • Added challenge in phakic vitrectomy surgery. • Access to vitreous base • Lenticular touch if vitrectomy is done too anterior • Post-operative cataract formation
- 25. • Addition of a scleral buckle did not improve the results and was associated with slightly lower VA compared to PPV alone • Lens status has no significant effect on success rate • Phakic eyes • 92% - pars plana vitrectomy alone • 87.5% - pars plana vitrectomy + encircling band • Pseudophakic eyes • 77.5% - pars plana vitrectomy alone • 86.7% - pars plana vitrectomy + encircling band Kinori M, Moisseiev E, Nadav, S. Comparison of pars plana vitrectomy with or without scleral buckle for the repair of Primary Rhegmatogenous Retinal Detachment Am J Ophthalmology. Aug 2011. Vol. 152. No. 2,
- 26. PHAKIC EYES AFTER VITRECTOMY • Cataract formation accelerates after vitrectomy surgery. • 02 exposure • Out of 376 phakic patients at study entry, 66.4% (250 out of 376) underwent cataract surgery either in combination with PPV or during the postoperative course. Holekamp NM, Shui YB, Beebe DC. Vitrectomy surgery increases oxygen exposure to the lens: a possible mechanism for nuclear cataract formation. Am J Ophthalmol. 2005;139(2):302-10. Heimann H, Zou X, Jandeck C, Kellner U, Bechrakis NE, Kreusel KM, Helbig H, Krause L, Schüler A, Bornfeld N, Foerster MH. Primary vitrectomy for rhegmatogenous retinal detachment: an analysis of 512 cases. Graefes Arch Clin Exp Ophthalmol. 2006 Jan;244(1):69-78. Epub 2005 Jul 26.
- 27. PREFERENCE • Pars plana vitrectomy surgery in all pseudophakic patients (majority - no band) • 23 G, endolaser/cryo, SF6 or C3F8, very rarely silicone oil
- 28. • Selective in phakic patients • Pediatric patients • Vitrectomy in patients with multiple breaks on 2 or more quadrants / different meridians • Macular hole detachments • Breaks posterior to the equator
- 29. DONEC QUIS NUNC
- 30. DONEC QUIS NUNC
- 31. CONCLUSIONS • Pars plana vitrectomy surgery as a stand alone surgery is as effective compared to combined scleral buckling + pars plana vitrectomy surgery in both pseudophakic and phakic eyes, and maybe associated with less complications. • Benefit maybe more seen in pseudophakic eyes as it induces less refractive change. • Surgeon preference and experience whether in placing or not band during vitrectomy surgery. • Decision making is a complex though process that no single algorithm is correct.
- 32. DONEC QUIS NUNC
- 34. • For giant retinal tears / large breaks : addition of buckle does not improve vitrectomy results
Editor's Notes
- This are my disclosures, but are not relevant to my topic on hand
- These are questions that are usually raised in the topic of vitrectomy surgery for retinal detachment, such as 1) Is pars plana vitrectomy surgery alone enough to repair most if not all uncomplicated RDs, and 2) Is it worth doing the extra step in adding a band, and does this change the final visual and anatomic outcome of the surgery
- The PAT Survey of the ASRS shows that in the United States, most of our colleagues tend to favor pars plans vitrectomy surgery compared the the worldwide trend of still doing scleral buckling
- However, in pseudophakic retinal detachments, the trend tends to the same, with a majority of us VR surgeons preferring to do a pars plana vitrectomy v.s that of doing a scleral buckle or combining a band with a vitrectomy. However, this did not state what type of tamponade is preferred for this cases
- So, what is the current trend. The current trend that we see is most VR surgeons will do a vitrectomy, with or without an encircling band, using smaller gauge vitrectomy probes with a majority using 23 G surgery. We also see a trend of VR surgeons using per fluorocarbon liquids in retinal detachment surgery. Retinopexy is mostly done using endolaser / cryopexy, with a few surgeons doing also laser indirect ophthalmoscopy. Tamponade preference is surgeon dependent, with most VR surgeons in North America prefer using gas versus that of oil in uncomplicated cases.
- PFCL usage has increased thru out the years, ever since Chang, et. al first used in in complicated retinal detachments. Its application has been to increase.
- VR surgeons who are more comfortable in placing a band in a combined surgery rationalize that the band provides additional support on the vitreous base, especially in pseudophakic patients who may have small micro-breaks in addition to an obvious retinal break. Also, the additional buckle will support breaks on the inferior meridian on the globe. The band also lessens the extent of residual vitreous traction on the retinal breaks itself which holds true on all quadrants.
- Now, VR surgeons preferring pars plana vitrectomy alone would base its’ rationalization that vitrectomy, especially with wide angled vitrectomy systems allow complete removal of the peripheral vitreous during surgery. The possibility of placing a 360 degree laser cerclage, which is less traumatic to cryopexy also is a contention that the peripheral retina can be stabilized without the need for a band.
- Hence, placing a band, will actually not give much advantage because in most reports for un-complicated retinal detachments, anatomic and functions success rates are similar. It induces a change in the refraction of the patient because of changes in axial length. The additional steps in placing a band has complications not seen in vitrectomy surgery alone, and in other settings, it adds up to the costs.
- Escoffery, et al first reported pars plana vitrectomy alone to repair a retinal detachment, and they achieved a SOSR of 79%, and with additional surgery, the success rate increased to 93%. His population was a nice mix of phakic, aphakic, and pseudophakic patients.
- Stangos and his co-authors reported one of the first prospective series in comparing PPV alone vs that of combined band/buckle and PPV in pseudophakic patients. He showed that re-attachment in the vitrectomy alone series is higher that the vitrectomy + buckle band population.
- While, Weichel and his co-authors did a retrospective case series in comparing primary PPV vs that of combined PPV + band/buckle, with the results of the combined a bit better, though they were not statistically different
- The VIPER study (Vitrectomy Plus Encircling Band Vs. Vitrectomy Alone For The Treatment Of Pseudophakic Retinal Detachment) a large scale study which dealt with the questions (1) whether the combination of 20 G vitrectomy and scleral buckling is superior to 20 G vitrectomy alone (control) (confirmatory), and (2) whether transconjunctival 23/25 G vitrectomy is non-inferior to 20 G vitrectomy (both without scleral buckling) regarding operation success. Vitrectomy with gas is an efficient and safe treatment for uncomplicated PRD. An additional encircling band does not significantly reduce the risk for any second procedure necessary to reattach the retina in 20 G vitrectomy. Small gauge transconjunctival vitrectomy is not inferior to the conventional 20 G technique.
- This study has shown that acceptable success rates can be achieved using PPV alone to treat RRD with inferior breaks. Complications are minimised and patients in this high risk group have an 81% chance of primary success. Pars plana vitrectomy and gas will successfully reattach the retina and a supplementary SB, to support the inferior retina, is unnecessary as the intraocular gas, and face up or, right or left side down positioning will tamponade breaks satisfactorily. A
- Wickman also observed that for inferior breaks, single operation success rate was higher with vitrectomy and gas vs that of combined vitrectomy, band, and gas. However, final success rate was statistically non significant
- The EVRS in 2011 attempted to answer the variables that affect final surgical outcome on both complicated and uncomplicated RD. It studied the surgery of choice, and it also studied manuever parameters (such as placing a band), phakic status, location and number of the breaks complicated RDs vs uncomplicated RDs, and to some extent tamponade used
- As for the surgical treatment, clearly, most would prefer vitrectomy surgery regardless of phakic status, though it did not detemine if removing the cataract at the same time will affect outcome
- However, in terms of vitrectomy outcomes, those with a concomitant buckle have higher chance of retained silicone oil or surgical failure
- It is also observed here that buckles do not improve vitrectomy results
- A short summary of the relevant parts of the EVRS RD study. Majority of members do vitrectomy surgery for retinal detachment. Addition of a scleral buckle/band in vitrectomy surgery is associated with higher complication rate, and no improvement in vitrectomy outcomes. Lens status plays importance in choosing the surgical procedure though most VR surgeons tend to do vitrectomy more. Surgeon preference and experience will decide whether putting a band is needed. where the case maybe difficult. It is also possible that surgeon who see more pathology will place a band, hence higher rate of failure, and less favorable outcome on this cases.
- Though vitrectomy surgery alone is gaining more popularity among our colleagues, scleral buckling alone is still a popular procedure, and as one colleague during the one of the meetings had mentioned, is becoming “a lost art. Phakic vitrectomy surgery poses challenges to both experienced and VR surgeons starting their practice. Among the challenges are 1) Access to the vitreous base, avoidance of lenticular touch, and post-operative cataract formation
- Despite the challenges, vitrectomy surgery in phakic eyes also showed a higher success rate compared to combined vitrectomy and band surgery as reported by Kinori and his co-authors
- As what was mentioned, phakic vitrectomies poses a challenge to most VR surgeons with cataract formation seen as one of the most common problems in primary vitrectomy surgery. Holekamp in her report showed that increased oxygen exposure during vitrectomy surgery irregardless of placing a band or not, and Heimann, showed that 66.4% will require cataract removal within 6 months to one year post-operative course
- My preference is not much different that most colleagues, though I almost exclusively gas as my primary tamponade in vitrectomy surgery for RD’s, with a preference to SF6 on breaks above the horizontal meridian, and C3F8 if there are breaks inferior to the horizontal meridian
- In phakic eyes, I repair a significant number of cases thru vitrectomy, in pediatric patients, where I use oil, breaks in more than 2 or more quadrants and on different meridians, for macular hole detachments, and breaks posterior to the equator
- Pars plana vitrectomy surgery as a stand alone surgery is as effective compared to combined scleral buckling + pars plana vitrectomy surgery in both pseudophakic and phakic eyes, and maybe associated with less complications. Benefit maybe more seen in pseudophakic eyes as it induces less refractive change. Surgeon preference and experience whether in placing or not band during vitrectomy surgery. Decision making is a complex though process that no single algorithm is correct.