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Original Article Outcome of rhegmatogenous repair by scleral buckling: The experience of a tertiary referral center in Scotland

Vikas Shankar, Lik Thai Lim, Elliott Yann Ah-Kee1, Harold Hammer

Tennent Institute of Ophthalmology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, 1University of Glasgow School of Medicine, University Avenue, G12 8QQ, UK

Purpose: The primary aim of this study is to report showed that the primary outcome (primary anatomical the outcome of patients with rhegmatogenous success following index surgery) was 90.77%, while retinal detachment (RRD) who underwent scleral the secondary outcome (anatomical success following buckling (SB) surgery. repeat surgery) was 98.46%.

Methods: This is a retrospective noncomparative case Conclusion: The study showed a high-success rate series study of all patients who underwent RRD repair of SB in phakic eyes both in terms of postoperative by primary SB between March 2008 and February 2009. best-corrected visual acuity and complication rates. Patient demographics, visual outcome, complications, We recommend the continued use of this technique in and failure rates were identified and recorded. selected cases of RRD.

Results: A total of 65 patients underwent RRD Keywords: Outcomes, retinal detachment, scleral repair by SB, with a mean age of 44.44 years. Results buckling

Introduction with national standards and to identify the causes of failure and complications. Rhegmatogenous retinal detachment (RRD) is primarily treated either by external approach with scleral buckling (SB), pars plana Methods (PPV) or both. SB has been falling out of favor over the last two decades and is quickly becoming a lost art of vitreoretinal This is a retrospective noncomparative case series study of the surgery. At present, the trend is toward PPV with advances such outcomes of SB technique for RRD repair performed from 1st March as small-incision techniques and wide-field viewing systems. In 2008 to 28th February 2009 at Gartnavel General Hospital, Glasgow. this study, we looked at the results of SB procedures performed Inclusion criteria included RRD requiring surgery using SB. at a tertiary center for treatment of RRDs. The main objective Patients with any previous RRD surgery, pseudophakic patients, of the study was to study the outcome of RRD repair using the aphakic patients, patients with giant retinal tears, posterior SB technique. We also sought to compare the surgical outcome breaks, proliferative vitreo-retinopathy (PVR) grade C, retinal detachment (RD) with vitreous hemorrhage, RD with choroidal Access this article online detachment and patients who had a history of strabismus surgery Quick Response Code: were excluded. The study included mostly adults with the age Website: of presentation ranging from 15 to 75 years with a mean age of www.ojoonline.org 47.44 years. Cases were identified from the operating theatre logbook at Gartnavel General Hospital. Case notes were then DOI: retrieved with the help of the medical records department. 10.4103/0974-620X.142595 Patient demographics, visual outcome, complications and failure rates were identified and recorded. The data collection sheet was

Copyright: © 2014 Shankar V, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Correspondence: Dr. Elliott Yann Ah-Kee, University of Glasgow School of Medicine, University Avenue, Glasgow, G12 8QQ, United Kingdom. E-mail: [email protected]

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Shankar, et al.: Rhegmatogenous retinal detachment repair by scleral buckling

completed, and results analyzed. All the patients had documented General anesthesia was used in 64 patients while one patient with posterior vitreous characterized by a Weiss ring detected on near term pregnancy was done under local (sub-tenon) anesthesia. fundoscopy. The variations in surgical technique used are shown in Table 2.

Results The buckles used were mostly segmental in 59 patients, and radial buckles were performed in five, while one patient had The total number of primary SB repair surgery performed during a circumferential buckle. All buckles were made of silicone. the 12-month period was 65 patients of which 38 were female. Prophylactic treatment with cryotherapy in the fellow eye was The age of presentation varied from 15 to 75 years with a mean required in 15 patients for suspicious areas, while one patient had age of 47.44 years. The right eye was involved in 40 patients. Five bilateral detachment. The buckles when placed radially were at surgeons were involved with Surgeon 1 performing 30 surgeries. 10 o’clock, 11 o’clock, and 2 o’clock hours in three patients. The The duration of symptoms ranged from 1 day to 3 months. choice of buckles used, is shown in Table 3. Three patients presented within 24 h, 12 within 1-2 days, 18 within 3-7 days, while 32 presented with symptoms of >7 days The intraoperative complications included vitreous hemorrhage duration. Forty-three patients (66%) underwent surgery within (n = 1), sub-retinal hemorrhage, while draining sub-retinal fluid 2 days of the presentation. Twenty-two patients had surgery (SRF) (n = 4), choroidal hemorrhage (n = 1), and tyre displaced after 3 or more days. The maximum waiting time for surgery was posteriorly (n = 1). Fifty-eight patients had no complications 6 weeks because the patient had a previous operation on the other intraoperatively [Table 4]. eye for RRD. More than half of the patients were myopes (54%), of which 23% were high myopes (>−6 D) (n = 15) and 31% were low RE UT UN LE UN UT myopes (n = 20), emmetropia in 24 (37%) and hypermetropia in 6 (9%). History of trauma was elicited in four patients including one patient who was a rugby player presenting with retinal 13 2 0 6 dialysis. Treated RD in the fellow eye was seen in three patients. Presenting symptoms are summarized in Table 1. LT LN LN LT The presenting visual acuity (VA) was 6/6 in 16 (24.67%) patients, 6/9-6/18 in 25 (38.5%) patients, 6/24-6/36 in 8 (12.3%) patients, 5 3 0 2 6/60 and less in 13 patients, hand movements (HMs) in three

patients. Two patients were amblyopic in the affected eye with Figure 1: Frequency of quadrant involvement in tears/breaks (UT = upper temporal; VA 6/60 and counting fingers. UN = upper nasal; LT = lower temporal; LN = lower nasal; RE = right eye; LE = left eye)

Of the 41 patients with VA better than 6/18, 37 patients had macula-on RD at presentation. Seven patients had macula-on RD RE UT UN LE UN UT by ultrasound, in which the detached was folded over the front of the macula. The rest (32%) had macula-off RD (n = 21). 6 2 0 3 All the patients who underwent an operation were phakic. Sixteen patients (25%) had retinal dialysis on presentation. The refractive status of most of the patients with dialysis was LT LN LN LT emmetropia (n = 11) with the rest having low (n = 5). The RDs resulting from dialysis was found in 16 cases (24.6%) and those resulting from tears/breaks in 21 cases (32.3%), while 3 3 3 4 holes were responsible in 28 cases (43.1%). Two patients had Figure 2: Frequency of quadrant involvement in holes suspicious breaks, but no clearly defined breaks/holes were identified. It was interesting to note that there is area specific predilection for the tears, dialysis and holes in this series of RD, RE UT UN LE UN UT highlighted in Figures 1-3. Moreover, some patients had more than one quadrant involved. 1 0 0 0 Table 1: Presenting symptoms

Symptoms Number of patients LT LN LN LT Floaters 31 Visual loss 29 Curtain 25 10 2 0 3 Flashes 12 Asymptomatic 12 Figure 3: Frequency of quadrant involvement in dialysis

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Shankar, et al.: Rhegmatogenous retinal detachment repair by scleral buckling

Postoperative complications included raised intraocular pressure repeat surgery. One patient failed to attend for further follow-up (n = 4), re-detachment (n = 6) and PVR grade C with vitreous and another one attended follow-up in another hospital. hemorrhage and new breaks in one patient. Epiretinal membrane developed in two patients. Residual SRF at macula was observed Figure 4 shows the presenting VA, and VA after one successful in two patients [Table 4]. Squint () developed in operation and subsequent repeat surgery for those who were one patient, but was successfully treated with Fresnel prism and unsuccessful after the first operation. Out of the 65 patients, subsequently resolved after 2 months. six needed repeat surgery with vitrectomy for persistent RD. Five of the six patients had good visual outcome and only one Follow-up developed PVR. Postsurgical follow-up is vital in that it ensures that the retina is in place and at the same time, it also helps to identify unsuccessful Repeat surgery cases for repeat surgery. Anatomical success was defined as Six patients who underwent repeat surgery for the persistent a reattached retina at the last postoperative visit. The shortest detachment were aged between 15 and 63 years, with a mean postoperative follow-up period was 2 weeks, while the longest age of 35.16 years. All patients were operated within 6 days of postoperative follow-up period was 6 months. Forty-two patients presentation. Four of the six patients were emmetropic, while the were followed-up for 2 months after which they were discharged. other two were low-myopes. The presenting VA was 6/9-6/18 in Eleven patients were discharged at 3 months. Six patients were three patients, 6/24-6/36 in two patients, and HMs in one patient. followed-up for 4-6 months. The postoperative best-corrected Four of the six patients had retinal dialysis (3 in 7-8 o’clock). VA (BCVA) was included for 58 patients and is shown in Table 5. One patient had retinal holes (3 holes 6-8 o’clock) and another patient had a horseshoe retinal tear (10 o’clock). Two patients had The follow-up results excluded the six patients who underwent macula-off RD, while three were macula-on RD with the retina folded in front of the macula. The final visual outcome after repeat Table 2: Variations in surgical techniques used surgery was 6/6 in two patients, 6/9 in one patient, while two Surgical technique Number of patients achieved 6/12 VA improvement. The patient who had a patients horseshoe retinal tear did not attend for follow-up. SB with cryotherapy and SRF drainage 52 SB with cryotherapy and air without SRF drainage 4 Discussion Dry tap on attempted SRF drainage 1 SB with cryotherapy alone 8 Scleral buckling is a very effective procedure in selected cases of SB: Scleral buckling, SRF: Sub-retinal fl uid RRD such as in uncomplicated phakic patients. Unfortunately, this

Table 3: Choice of buckles used Type of buckle Number of patients Table 5: Postoperative corrected visual acuity of Solid silicone 220 6 follow-up patients Solid silicone 276 2 Visual acuity Number of patients Solid silicone 277 40 6/6 37 Solid silicone 279 7 6/9-6/18 13 Solid silicone 240 and 277 combined 1 6/24-6/36 4 Sponge silicone 505 2 <6/60 3 Sponge silicone 506 7 Hand movements 1

Table 4: Complications of SB surgery Complications Number of patients Intraoperative complications Vitreous hemorrhage 1 Sub-retinal hemorrhage (while SRF drainage) 4 Choroidal hemorrhage 1 SB displaced posteriorly 1 Postoperative complications Raised IOP 4 Re-detachment 6 PVR with vitreous hemorrhage with new breaks 1 ERM 2 Residual SRF 2 Squint (double vision) 1 Figure 4: Graph illustrating the presenting visual acuity, and visual acuity after one SB: Scleral buckling, SRF: Sub-retinal fl uid, IOP: Intraocular pressure, successful operation and subsequent repeat operations for those who were unsuccessful PVR: Proliferative vitreo-retinopathy, ERM: Epiretinal membrane after the fi rst operation

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Shankar, et al.: Rhegmatogenous retinal detachment repair by scleral buckling

technique is performed less frequently due to the introduction after retinal reattachment using the encircling procedure for of PPV in early 1970s. However, SB has multiple advantages RRD. However, it improved after relaxation of the buckle, which over PPV, including reducing the risk of cataract formation and restored the ocular blood flow.[5] The report suggested that the endophthalmitis. It has faster visual rehabilitation compared to choroidal circulation disturbance, which was found following the PV, which requires intra-vitreal gas or silicone oil.[1] Furthermore, encircling procedure, had a plausible role in the development of in certain cases like retinal dialysis, SB is the treatment of choice, the visual field defect.[5] We did not notice any visual field related with a better prognosis and success rate.[2] complications in our series.

However, SB technique is more difficult to learn and teach Sub-macular fluid was seen in two patients (3%) in our case compared to PV. It is also demands more surgical expertise series, one of which resolved in the follow-up. The incidence, compared to PPV, which has the advantage of intraoperative pattern, duration, and clinical consequences of persistent, localized visualization of retinal breaks. sub-macular fluid after SB surgery for RD has been reported in the literature in a prospective observational cohort series.[6] Ninety-eight Success patients had an optical coherence tomography (OCT) scan of In our study, the primary outcome (primary anatomical success the macula preoperatively and at 6 weeks postoperatively. Of the following index surgery) is far better than that reported in the 98 patients recruited in the study, 54 (55%) had SRF on OCT 6 weeks national average, although the secondary outcome (anatomical after surgery. Fluid was associated with delayed visual recovery. Of success following repeat surgery) is more or less the same as that those with SRF, 78% had persistent fluid at 6 months, and resolution reported by the national average.[3] The postoperative BCVA was of fluid took a median of 10 months and was associated with an 6/6 in 37 patients (56%). Thirteen patients achieved 6/9-6/18, improvement in vision.[6] The study concluded that persistent SRF while four had VA between 6/24 and 6/36. Thus, 76.9% patients 6 weeks following SB, occurs in approximately half of patients. achieved a VA better than 6/18 postoperatively after the primary Furthermore, this may persist for many months and cause delayed procedure. The VA of <6/60 was seen in three patients. Of those, visual recovery.[6] In our case series, two patients had residual SRF, two had preexisting amblyopia. One patient was left with VA of which was absorbed in the subsequent follow-up of 2 months. HM only. Moreover, one patient failed to follow-up, while six patients required repeat surgery. A retrospective, noncontrolled case series study was conducted in 93 patients (93 eyes) to evaluate the outcome of patients who Postoperative complications had previous macula-off RRD treated with SB.[7] Patients with In our study, only one patient experienced double vision (1.5%) low-grade myopia (<−6 D) regained significantly better mean due to exotropia. This was treated conservatively by prism and postoperative VA as compared with high myopia (>−6 D) and resolved in 2 months. In a study of 821 patients who underwent SB, emmetropic eyes (0 to + 3 D) (ANOVA, P < 0.001). In this series, 12 developed diplopia lasting >3 months. Six of the SB operations SRF drainage procedure did not affect postoperative visual were vertical, three horizontal, and three oblique. Examination outcome. Multivariate logistic regression analysis revealed of the 12 patients showed seven cases of hypertropia, two cases that the duration of macular detachment was the only variable of hypertropia associated with esotropia, one case of hypertropia affecting the visual outcome.[7] with exotropia, and two cases of exotropia. The SB was removed in all 12 patients; binocular single vision was restored in six cases. A study of eyes with primary, uncomplicated, macula-off Secondarily, prism correction restored binocular vision in three RD repaired with SB, concluded that eyes achieve excellent additional patients. Strabismus surgery was necessary for the postoperative VA if repaired within the first 10 days of macular remaining three patients.[4] detachment.[8] Patient age did not significantly affect anatomical outcomes.[8] Buckle-related complications following surgical repair of retinal dialysis has been reported in a study of 28 cases. Anatomical In a large case series of 186 eyes, 82% achieved retinal reattachment success was achieved with a single procedure in 26 cases (92.9%). with one SB procedure and with a median final VA of 20/40 at Compared to our study, the primary success rate for related cases 20 years of follow-up.[9] An additional 30 eyes (13%) achieved was lower at 75%. However, the secondary success rate is almost retinal reattachment after one or more additional vitreo-retinal similar.[2] Postoperative complications were seen in 20 cases procedures, with a median final VA of 20/50. Eleven eyes (5%) (71.4%), with complications attributable to the buckle noted developed RD at the 20-year follow-up examination, with a final in 19 cases (67.9%).[2] Buckle-related complications included VA in all eyes of no light perception. This study may serve as a exposure (n = 7; 25%), strabismus (n = 5; 17.9%), and infection basis for comparison with the long-term results of other surgical (n = 3; 10.7%).[3] In contrast, the complications attributable to techniques used in the treatment of primary RRDs.[9] Our success SB in our study, were minimal with only one patient developing rate is comparable to the above study, as we have achieved success a strabismus, which was treated with prisms. None required after one procedure of 90.77% and 98.46% after two procedures. removal of buckle, although the follow-up of the patient is shorter. The National RD Audit, UK reported primary reattachment in 82% The case has been reported of a patient with visual field defect and the final reattachment as 91%.[10] In a randomized controlled

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trial of 546 patients, favorable surgical outcomes for primary rhegmatogenous retinal detachment: A prospective randomized RRDs with SB alone was achieved in 97.8% of the patients.[11] multicenter clinical study. Ophthalmology 2007;114:2142-54. 4. Sauer A, Bouyon M, Bourcier T, Speeg-Schatz C. Diplopia complicating scleral buckling surgery for retinal detachment. J Fr Ophtalmol From the results of our study, we observed that there are few 2007;30:785-9. factors that may be contributing toward the failure of the minority 5. Kimura I, Shinoda K, Eshita T, Inoue M, Mashima Y. Relaxation of encircling of cases reported in this study. Patients with dialysis were noted to buckle improved choroidal blood fl ow in a patient with visual fi eld defect have a higher incidence of failure rate after first surgery. The sample following encircling procedure. Jpn J Ophthalmol 2006;50:554-6. 6. Benson SE, Schlottmann PG, Bunce C, Xing W, Charteris DG. Optical size of our study is too small to draw a significant correlation coherence tomography analysis of the macula after scleral buckle surgery between success rate and duration of symptoms of RRD. However, for retinal detachment. Ophthalmology 2007;114:108-12. the latter appears to have some bearing on the overall success 7. Yang CH, Lin HY, Huang JS, Ho TC, Lin CP, Chen MS, et al. Visual of a first RRD repair using the SB technique. Persisting RD will outcome in primary macula-off rhegmatogenous retinal detachment eventually develop into PVR, which can further reduce the chance treated with scleral buckling. J Formos Med Assoc 2004;103:212-7. 8. Hassan TS, Sarrafi zadeh R, Ruby AJ, Garretson BR, Kuczynski B, of a successful first-time operation. Williams GA. The effect of duration of macular detachment on results after the scleral buckle repair of primary, macula-off retinal detachments. Conclusion Ophthalmology 2002;109:146-52. 9. Schwartz SG, Kuhl DP, McPherson AR, Holz ER, Mieler WF. Twenty-year follow-up for scleral buckling. Arch Ophthalmol 2002;120:325-9. Scleral buckling is still a very effective technique to treat selected 10. Thompson JA, Snead MP, Billington BM, Barrie T, Thompson JR, cases of RD, and as such should not be a neglected skill for Sparrow JM. National audit of the outcome of primary surgery for present and future vitreo-retinal surgeons, despite in the advent rhegmatogenous retinal detachment. II. Clinical outcomes. Eye (Lond) of advancing techniques and technology of PPV. 2002;16:771-7. 11. Pastor JC, Fernández I, Rodríguez de la Rúa E, Coco R, Sanabria-Ruiz Colmenares MR, Sánchez-Chicharro D, et al. Surgical outcomes References for primary rhegmatogenous retinal detachments in phakic and pseudophakic patients: The Retina 1 Project – Report 2. Br J Ophthalmol 1. Azad RV, Chanana B, Sharma YR, Vohra R. Primary vitrectomy versus 2008;92:378-82. conventional retinal detachment surgery in phakic rhegmatogenous retinal detachment. Acta Ophthalmol Scand 2007;85:540-5. Cite this article as: Shankar V, Lim LT, Ah-Kee EY, Hammer H. Outcome of 2. James M, O’Doherty M, Beatty S. Buckle-related complications following rhegmatogenous retinal detachment repair by scleral buckling: The experience surgical repair of retinal dialysis. Eye (Lond) 2008;22:485-90. of a tertiary referral center in Scotland. Oman J Ophthalmol 2014;7:130-4. 3. Heimann H, Bartz-Schmidt KU, Bornfeld N, Weiss C, Hilgers RD, Source of Support: Nil, Confl ict of Interest: None declared. Foerster MH, et al. Scleral buckling versus primary vitrectomy in

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