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ORIGINAL ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 1-9

360° laser retinopexy in preventing retinal re-detachment after 23-gauge vitrectomy for primary repair of retinal detachment


Department of Ophthalmology, Medical School, Cairo University, Cairo, Egypt

Date of Web Publication29-Mar-2016

Correspondence Address:
Omar A Barrada
6 A Giza Street, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-5617.179339

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  Abstract 

Aims: To evaluate the role of intraoperative 360° laser retinopexy in the prevention of retinal re-detachment in cases of primary rhegmatogenous retinal detachment (RRD). Settings and Design: Prospective randomized controlled trial, 80 eyes of 80 patients with primary RRD. Subjects and Methods: Totally, 80 eyes of 80 patients with primary RRD will be divided into two groups. In Group (A), laser will be applied to all existing breaks as well as 360° laser retinopexy anterior to the equator will be performed while Group (B) laser will be applied only to the retinal breaks and will not receive the 360° laser treatment. Follow-up was for 3 months after clearance of the tamponading agent. Statistical Analysis Used: Backward logistic multi-regression analysis identified significant independent predictors of re-detachment (P < 0.01, Hosmer-Lemeshow, χ2: 7.593, P = 0.474). Results: Backward logistic multi-regression analysis identified significant independent predictors of re-detachment (P < 0.01, Hosmer-Lemeshow, χ2: 7.593, P = 0.474): Duration of detachment and preoperative visual acuity. Specifically, for every day more of duration of detachment, the odds of re-detachment increased by a factor of 1.007 (P < 0.01). Likewise, for every day more of duration of detachment, the odds of re-detachment was increased by a factor of 8.840 if a preoperative visual acuity of hand motion with bad projection (HMBP) or worse was present (P = 0.05). Conclusions: We concluded that prophylactic intraoperative 360° laser retinopexy did not have a statistically significant role in the prevention of retinal re-detachment after primary retinal repair. The statistically significant preoperative risk factors that have a poor prognostic effect on surgical outcomes are preoperative visual acuity of ≤ HMBP or worse and a longer duration of the retinal detachment.

Keywords: 360° laser retinopexy, retinal re-detachment, vitrectomy


How to cite this article:
Barrada OA, Nabih MH, Khattabm AM, Nosseir AA. 360° laser retinopexy in preventing retinal re-detachment after 23-gauge vitrectomy for primary repair of retinal detachment. Egypt Retina J 2015;3:1-9

How to cite this URL:
Barrada OA, Nabih MH, Khattabm AM, Nosseir AA. 360° laser retinopexy in preventing retinal re-detachment after 23-gauge vitrectomy for primary repair of retinal detachment. Egypt Retina J [serial online] 2015 [cited 2019 Oct 20];3:1-9. Available from: http://www.egyptretinaj.com/text.asp?2015/3/1/1/179339


  Introduction Top


Rhegmatogenous retinal detachment (RRD) is a serious, potentially sight threatening condition. If it does not promptly and effectively treated, it may leave the eye dysfunctional and atrophic. Retinal detachment occurs in 1 in 10,000-20,000 persons/year. [1],[2],[3] Successful repair of RRD has been reported since the 1930s, and numerous techniques have resulted in improved surgical outcomes. Primary retinal detachment repair techniques include scleral buckling alone, pars plana vitrectomy (PPV) alone, a combination of scleral buckling and PPV, and pneumatic retinopexy. Although all techniques show high re-attachment rates, each procedure has its own drawbacks and complications.

Pars plana vitrectomy was described my Machemer et al. in the early 1970s. [4] The first PPV involved a multifunction single-port device, 17-gauge (G) in diameter, which was introduced through a 2.3 mm sclerotomy site. The quest to find ways to shorten operative time and to minimize trauma to the eye has led to considerable improvement in surgical techniques and equipment. In 2002, Fujii et al. [5] presented a set of tools with a diameter of 25-G, followed by the 23-G system, which was introduced by Eckardt in 2005. [6]

An important part of vitrectomy for RRDs entails performing retinopexy around all existing breaks in order to insure their long-term closure. Laser retinopexy works by creating a chorioretinal scar that seals the break, preventing fluid from re-entering behind the retina causing it to re-detach. [7] Vitreous substitutes, such as gas or oil, help in sealing any breaks and keeping the retina attached until the laser scar is strong enough, after which the presence of the tamponading agent is no longer necessary, and then its spontaneous absorption or surgical removal is recommended. Removal of silicone oil (SO) is especially important, as most anterior segment complications associated with its use is related to the length of time that oil is retained in the eye. [8],[9] However, with the disappearance of the tamponading agent, the main risk is the possibility of retinal re-detachment. [10],[11]

Surgical modalities such as placement of a supplementary scleral buckle, [12],[13] panretinal photocoagulation [14] and 360° laser retinopexy [15],[16],[17],[18] are used in an attempt to decrease the rate of retinal re-detachment after clearance of the tamponading agent. Intraoperative 360° laser application is quick and easy, and for a long time, has been regarded as useful in reducing re-detachment rates. Studies have shown that the major causes of retinal re-detachment are missed breaks, opening of old breaks due to persistent or renewed traction or new break formation. [9],[19] Theoretically, application of laser retinopexy circumferentially may serve to reduce the rate of re-detachment by walling off any detachment that might occur anterior to the barrage. [17] Also, any missed breaks might be treated unintentionally; sealing them off.

The aim of this study is to directly evaluate the effect of intraoperative 360° laser retinopexy anterior to the equator in the prevention of retinal re-detachment after either the removal (SO) or absorption (gas) of the tamponading agent in cases of primary RRDs treated with 23-G transconjunctival sutureless vitrectomy.


  Subjects and Methods Top


In this prospective randomized controlled interventional study, 80 consecutive eyes suffering from primary RRD were treated with 23-gauge transconjunctival vitrectomy. Those 80 eyes were divided into two groups: In Group (A) endolaser was applied to all existing breaks as well as 2-3 rows of 360° laser treatment in the area of the vitreous base. Group (B) laser was applied only to the retinal breaks and did not receive the 360° laser treatment. Randomization was done after flattening of the retina and application of laser around all existing breaks. All patients were recruited between October 2011 and July 2012 [Chart 1 [Additional file 1]].

Inclusion/exclusion criteria

Patients included were those with primary RRDs with various grades of proliferative vitreoretinopathy (PVR) except for grade D (including sub-retinal membranes). Patients with a coincidental cataract that necessitated its simultaneous removal were also included. Patients with previously failed retinal procedures (previous scleral buckle, failed vitrectomy, pneumatic retinopexy or laser barrage treatment), other retinal pathologies such as diabetic retinopathy, macular holes, giant breaks or dialyzes were excluded. Intraoperatively, any detachment in which relaxing retinotomies had to be performed was also excluded from this study.

Preoperative/postoperative examination

Preoperatively a full history, including any history of trauma, previous ophthalmic surgeries or procedures and the duration of detachment were noted. Best-corrected visual acuity, slit lamp examination of anterior segment structures, indirect ophthalmoscopy, and slit lamp biomicroscopy were done. PVR was graded according to the updated Retina Society classification. Pupil size of the affected eye was measured under maximal photopic conditions using the slit beam of the slit lamp and was compared to the size of the pupil in the other healthy eye.

Examination was scheduled at baseline then at 1-day, 1-week, 1-month then monthly until 3 months post SO removal or gas absorption. At follow-up, the state of the retina, intraocular pressure (IOP), pupil size as well as any other observations were noted.

Surgical technique

Surgery was performed under general or local anesthesia with retrobulbar block. The surgical procedure was based on the 23-G transconjunctival sutureless vitrectomy one-step system (Alcon Laboratories, Inc., Fort Worth, TX, USA). The conjunctiva was displaced and 30° angled incisions were made through conjunctiva, sclera, and pars plana 3.5-4 mm from the corneoscleral limbus with a 23-gauge blade-trocar system in order to obtain tunnels parallel to the corneoscleral limbus. The ACCURUS or CONSTELLATION vitrectomy system with dual pneumatic cutters and halogen bulb light source (Alcon Laboratories, Inc., Fort Worth, TX, USA) was used for all cases. The IOP was maintained between 30 and 40 mmHg. The three-dimensional-vitrectomy mode with cutting rate up to 5000 cuts/min (cpm) and vacuum of up to 500 mmHg was used. A core vitrectomy was performed after the induction of posterior vitreous detachment using cutting off mode with high vacuum in all cases. Perfluorocarbon liquid was used at the discretion of the surgeon to flatten the posterior retina. The vitreous-base was thoroughly trimmed with the help of scleral indentation; no relaxing retinotomies were done, although draining retinotomies were done if posterior subretinal fluid was noted. Triamcinolone Acetonide was used at the surgeons' discretion for staining of the vitreous. After complete removal of the vitreous, any epiretinal membrane was dissected and removed. Then the retinal periphery was inspected for retinal breaks, and any break found was treated with laser retinopexy. Fluid-air exchange was then performed. At this point, the eyes enrolled in this study were randomly assigned to either receive 2-3 rows of 360° laser retinopexy in the area of the vitreous-base or not. The laser shots were made to be clearly visible with whitening of the retina as to insure good retinopexy. Also, the eyes were randomized to be either left with a nonexpansile mix of gas (either SF6 or C2F6) or 1000 centistoke (cSt.) SO as a tamponading agent. After insuring an adequate fill of either tamponading agent, the trocar cannulas were slowly removed, and the sclerotomies gently massaged with a blunt solid instrument. Sclerotomy sights were meticulously examined for any leaks and sutured if their self-sealing ability was in doubt. Postoperative treatment consisted of topical antibiotic drops, a topical steroid preparation both q.i.d. and a combined antibiotic/steroid ointment at night for a period of 1-month. Posturing was maintained for 1-week, and SO removal was planned after a period of 3 months after the initial surgery. SO removal was either done through an anterior approach entailing phacoemulsification followed by a posterior capsulorhexis through which saline was infused while concomitantly removing the oil either passively by depressing the corneal wound or actively by aspiration by a 20-G cannula or the oil was removed through the posterior approach by inserting 3 23-G cannulas and removing the oil through both active suction and/or passive diffusion. The decision to use either technique was governed by if the patient needed a simultaneous lens removal at the time of oil extraction or not.

Outcome measures

The primary outcome measure is the success rate of retinal re-attachment throughout the follow-up period up until 3 months after either spontaneous absorption (gas) or active removal (silicone) of the tamponading agent. Secondary outcome measures are any complications related to the 360° laser application.


  Results Top


Patients analysis

During the preoperative examination, PVR was found in 73 (91%) of the cases. PVR grade (A) was present 15%, grade (B) in 41.3%, grade (C) in 35% and no PVR in 8.8% of the cases. The mean duration of the detachment, which is defined as the time passed since the patient noticed his symptoms to the time of the surgery, was 54.3 days (standard deviation [SD] 18.7) (range: 1-365 days) [Table 1].
Table 1: Demographics of patients recruited

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Retinal re-detachment analysis

The overall primary success rate of retinal re-attachment is 72.5% (58/80 eyes). Specifically, 9 out of the 22 eyes with a re-detachment had received 360° laser during the primary vitrectomy (41%) and the remaining 13 had not received such laser treatment (59%). In all 22 cases in which the retina redetached, the re-detachment occurred within 2 months of either removal or absorption of the tamponading agent. Specifically, 59.1% of the re-detachments occurred during the 1 st month, and the remaining 40.9% detached within the 2 nd month posttamponade clearance [Table 2].

The final retinal re-attachment rate was 85% (68/80 eyes). During the follow-up period, only 10 of the 22 eyes that had a retinal detachment after primary intervention returned for follow-up and reoperation, the remainder 12 eyes were lost to follow-up secondary intervention was never done. The number of eyes re-operated on that had the 360° laser treatment was five eyes, and the remaining five had not received prior 360° laser treatment. All of the eyes had an attached retina for 3 months after removing of the SO after secondary intervention. The data and causes of retinal re-detachment in those eyes are explained in [Table 3].
Table 2: Characteristics of the retinal detachments

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Table 3: The characteristics of the retinas that failed with primary repair and how the retinas were finally reattached

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Multi-variate analysis of all factors was done to identify those factors that had a statistically significant effect on the rates of re-detachment. The factors revealed in this analysis are preoperative visual acuity and the duration of retinal detachment (irrespective of the presence of PVR). PVR itself was not a statistically significant factor.

Retinal re-detachment occurred in 22.5% of patients that had any grade of PVR versus only 5.0% of those patients that did not have PVR (P = 0.06), which is not statistically significant. But, when sub-analysis was done, it revealed that specifically grade C PVR compared to other PVR grades was a statistically significant factor for poor surgical outcomes (grade A vs. C P = 0.05) (grade B vs. C P = 0.06). Surprisingly when compared to the absence of PVR there was no statistically significant correlation, but that could be explained by the very small number of eyes that did not have any grade of PVR (n = 12).

Analysis also showed that patients with preoperative visual acuity of ≤ hand motion with bad projection (HMBP) had a statistically higher rate of retinal re-detachment versus patients with visual acuity of ≥ hand-motion with good projection (HMGP) (P ≤ 0.01).

The duration of the detachment, irrespective of the presence or absence of PVR, had a statistically significant influence on rates of re-detachment (P ≤ 0.01). In the eyes in which the retina did not re-detach the mean duration of detachment in days was 35.9 ± 12.3 (range: 1-365) and in the eyes that the retina re-detached was 102.7 ± 91.2 (range: 2-365). Analysis of the impact of the duration of the detachment coupled with the presence or absence of the 360° laser treatment showed that in the eyes that had a recurrent detachment and received 360° laser had a mean duration of 81.44 days SD 29.28 days, median of 90 days (range: 2-210 days). As for the eyes that did not receive the laser treatment the mean duration of the detachment preoperatively was 111 days SD 47.8 days, median 60 days (range: 14-365 days) (P = 0.42).

Backward logistic multi-regression analysis identified significant independent predictors of re-detachment (P < 0.01, Hosmer-Lemeshow, χ2: 7.593, P = 0.474): Duration of detachment and preoperative visual acuity. Specifically, for every day more of duration of detachment, the odds of re-detachment increased by a factor of 1.007 (95% confidence interval [CI]: 1.000-1.015, P < 0.01). Likewise, for every day more of duration of detachment, the odds of re-detachment was increased by a factor of 8.840 if a preoperative visual acuity of HMBP or worse was present (95% CI: 2.507-31.102, P = 0.05).

Retinal re-detachment occurred in 11.3% of the patients that received 360° laser versus 16.3% of those that did not (P = 0.32). It clearly shows that the application of 360° laser did not significantly reduce the incidence of retinal re-detachment [Graph 1 [Additional file 2]].

Other factors analyzed to assess if they had a significant influence on retinal detachment were sex, history of trauma, total versus subtotal detachments, macula on versus macula off detachments, number of tears, the presence of inferior tears, and pseudophakia. All of which did not have a statistically significant influence on the incidence of retinal re-detachment after primary repair with 23-G transconjunctival vitrectomy [Table 4] and [Table 5].
Table 4: Analysis of different factors contributing to retinal re-detachment

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Table 5: Causes of retinal re-detachment

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Six eyes included in this study needed a combined phaco-vitrectomy procedure. Only two of these six eyes had a recurrent retinal detachment. The cause of re-detachment in these eyes was incomplete posterior hyaloid removal. There was no statistically significant relationship between combined phaco-vitrectomy surgery and the occurrence of postoperative PVR or re-detachment rates [Table 6].
Table 6: Relationship between phaco-vitrectomy and postoperative PVR/re-detachment rates

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Visual acuity analysis

Of the 80 patients, 36.3% had a visual acuity of HMBP or worse, and the remaining 63.8% had a visual acuity of HMGP or better (from light-perception with bad projection to 1.0 decimal).

It is worth noting that visual acuity assessment pre- and post-SO removal revealed that visual acuity improved from 0.12 ± 0.16 (range: 0.001-0.70) before SO removal to 0.27 ± 0.23 (range: 0.001-1.0) (P ≤ 0.01) after oil removal.

According to Journal of Cataract and Refractive Surgery guidelines, counting fingers vision is translated into 20/2000 (0.01 decimal) and hand motion vision (without discriminating between good and bad light projection) to 20/20000 (0.001 decimal).

These same guidelines state that light-perception (PL) must be eliminated from the analysis because this notation cannot be transformed into a decimal value.

Using these guidelines (preoperative VA)

Overall sample (decimal notation): Mean 0.03 SD 0.15 median 0.001 range from 0.001 to 1.

As may be expected, the difference between preoperative VA and VA before oil removal (P < 0.01) and after oil removal (P < 0.01) was statistically significant.

According to the presence or absence of re-detachment

In the no re-detachment group, the preoperative VA: Mean 0.04 SD 0.17 median 0.001 range from 0.001 to 1.

In the re-detachment group, preoperative VA: Mean 0.003 SD 0.007 median 0.001 range from 0.001 to 0.03.

The difference in preoperative VA between re-detachment and non-re-detachment groups was not statistically significant (P = 0.94). But this has to take into consideration that PL vision or the differentiation between HMGP and HMBP was not taken into account, as there is no method of translating these different visual acuities into numbers (e.g., decimal notation) for comparison and analysis.

Relationship between preoperative visual acuity of ≤ HMBP/360° laser and surgical outcomes [Table 7].
Table 7: The relationship between preoperative visual acuity of ≤HMBP/360 laser and surgical outcomes

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Pupil size analysis

The mean pupillary diameter in millimeters (mm) in all the eyes that had vitrectomy was 3.3 ± 1.0 mm versus 2.2 ± 0.4 mm in the other eye. The difference between them was 1.0 ± 0.9 mm.

Postoperatively, the difference between the pupillary diameter of eyes that received the 360° laser treatment and the other, healthy, eye was 1.18 ± 0.95 mm. While the difference in diameter of the pupils that did not receive the laser treatment when compared to their other healthy eyes was 0.87 ± 0.87 mm (P = 0.05), which shows that there is a statistically significant relationship between the application of 360° laser and a larger postoperative pupil size.

Tamponade agent analysis

As mentioned, the patients were randomized into one of the four groups, each group was composed of 20 patients: Gas plus 360° laser, gas without 360° laser, SO plus 360° laser and SO without 360° laser. Of the 22 eyes that had a retinal re-detachment, 13 of those eyes had gas as a tamponade (59%) and the remaining 9 eyes were tamponaded with SO (41%) [Table 8].
Table 8: Tamponading agents

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The gas used was SF6 in 28 patients (70%) and C2F6 in 12 patients (30%). 1000 (cSt) SO was used in the remaining 40 patients. Of the patients that were left with SO as a tamponade, the oil was removed in 23 (57.5%) using the posterior approach and the remaining 17 (42.5%) was removed via the anterior approach. There was no relationship between the method of oil removal and the incidence of retinal re-detachment. The relationship between using either gas or oil to the rates of retinal re-detachment was not statistically significant (P = 0.32) [Table 9].
Table 9: Relationship between each subgroup of eyes and the rate of retinal re-detachment

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  Discussion Top


Even with the continuous improvement in surgical outcomes witnessed over the last decade, vitrectomy for RRDs is still far from perfect. Success rates of primary repair range from 62.6% to 98.3% and 80% to 96.2% for 20-gauge and 23-G vitrectomy respectively. [20] Primary success in surgery for RRDs is of utmost importance. Studies have shown that visual recovery decreases exponentially with subsequent surgeries. [9],[21] Various surgical maneuvers were explored in an effort to reduce the risk of retinal re-detachments. The most important of these were the addition of a scleral buckle and more recently the use of 360° retinopexy. [22]

The use of 360° laser has long been thought to decrease the incidence of re-detachment. Until recently very little data had been published to clearly settle this point. Most of the papers published have either compared retinal detachment rates, with and without 360° laser, in procedures done for pathologies other than RRDs, such as macular holes and membrane peels, [17],[23] or have tried to demonstrate that 360° laser reduces the rate of re-detachment before SO removal. In those studies, the laser was usually applied weeks before the oil was removed and not intraoperatively. [15],[16],[18]

Removal of SO can be followed by a recurrent retinal detachment. [24] The incidence is widely variable: Most studies have reported an incidence of 20-25% [9],[25],[26],[27] some 15-20% [11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30] and a few below 10%. [26],[31],[32] Several mechanisms have been advocated for re-detachments, reopening of preexisting breaks, posterior migration of an occult detachment, new break formation and residual vitreoretinal traction at the vitreous base. [18],[19] In a small series of 31 eyes by Tufail et al., the application of 360° laser reduced the incidence of re-detachment from 25% to 6.7%. [15] In another series by Ahluwalia and Gray, the rate went down from 44% to 11%. [31] Avitabile et al. found that in 303 eyes 360° laser reduced the incidence of re-detachment from 21.4% to 8.6%. [18] The most recent study by Nagpal et al. conducted in 2012 came to the same conclusion as the previously mentioned data; they found that 360° laser reduced the risk of re-detachment from 22.33% to 8.98%. [32] The papers published by Tufail, Ahluwalia were done to assess if 360° laser treatment 2-3 weeks prior to SO removal decreased the rate of re-detachments. The paper by Nagpal et al. did not just assess the role of 360° laser, but also assessed, in another sub-group of eyes, the additive value of an encircling band. A third subgroup received both the 360° laser and the encircling band. The eyes that received a band had a re-detachment rate of 6.42% versus 17.82% in those that had not. The combination of the laser treatment and the band reduced the re-detachment rate from 16.73% to 4.20%. The paper concluded that both the laser treatment and/or the band reduced retinal re-detachment rate.

To our knowledge, the only study in the literature that reports the results of 23-G vitrectomy with 360° laser retinopexy in primary RRDs was a recently published retrospective paper by Yanyali et al. in 2012. [33] They reported a success rate of 95.9%. This study recruited 49 eyes with a mean duration of the detachment of 49 ± 85 days (range: 4-365 days) all of whom received 360° laser. To our knowledge, our paper is the only prospective randomized interventional study conducted to specifically assess the benefits and risks of 360° laser retinopexy in 23-gauge vitrectomy for primary rhegmatogenous detachments.

360° laser and surgical failure

In our study, the overall success rate for primary repair of RRDs was 72.5%, and a final re-attachment rate of 85%. These results are lower than most published data, especially more recent papers that reported primary success rates between 80% and 96.2%. [20] There are numerous explanations as to why our results differ from the more recently published data. The eyes that had been recruited in the other studies had macula-on detachments in 37-54% of the cases. Minimal PVR (grade B or less), and an average duration of the detachment of 7 days. [34],[35],[36] In contrast, we had macula on detachments in only 3.6%, PVR in 91%, including 35% with PVR grade C, and the average duration of the detachments was 54.3 ± 80.7 days in our study group. Also in contrast to previously published data, which clearly showed a reduction in re-detachment rates with 360° laser, our results did not show such benefit. Re-detachments in our study group occurred in 25% of laser-treated eyes versus 32.6% of nonlasered eyes (P = 0.32).

Previously numerous factors have been shown to be associated with failure to reattach the retina. The duration of symptoms, low preoperative visual acuity, myopia, amblyopia, hypotony, macular detachments, preoperative PVR, extent of the detachment, involvement of inferior quadrants, undetectable breaks, large breaks, breaks posterior to the equator, surgeon factor and level of surgical training. [37]

Duration of retinal detachment and surgical failure

The two strongest predictors of surgical failure in our study were preoperative visual acuity and the duration of retinal detachment (P ≤ 0.01). In the eyes in which the retina did not re-detach, the mean duration of detachment in days was 35.9 ± 12.3 (range: 1-365) and in the eyes that the retina re-detached was 102.7 ± 91.2 (range: 2-365). James et al. investigated the success rate after surgery for chronic retinal detachments (defined as duration of ≥3 months) and found that after exclusion of PVR, the success after single procedure was seen in 8 of 14 cases (57.1%) of chronic retinal detachments versus 92 out of 107 (86.0%) of fresh retinal detachments. [36]

In our study, analysis of the impact of 360° laser in the surgical outcome in relationship to the duration of the retinal detachment showed that in the eyes that had a recurrent detachment and received 360° laser had a mean duration of retinal detachment of 81.44 days SD 29.28 days, median of 90 days (range: 2-210 days). As for the eyes that did not receive the laser treatment the mean preoperative duration of the detachment was 111 days SD 47.8 days, median 60 days (range: 14-365 days) (P = 0.42). Again this data shows that there is no statistically significant difference between the duration of the detachments in both groups; that with 360° laser and the group without. Therefore, allowing us to conclude that, according to our study, 360° laser treatment does not have any statistical benefit in increasing the surgical success rates in chronic retinal detachment repair.

Preoperative visual acuity and surgical failure

In our study, eyes with preoperative visual acuity of ≤HMBP had a 20% chance to develop a re-detachment compared to 7.5% in eyes with ≥HMGP (P = 0.01). The explanation for this observation is that visual acuity of ≤HMBP is usually associated with other risk factors for re-detachment, such as chronicity of the condition and the presence of PVR. The correlation of preoperative visual acuity to surgical outcome was also demonstrated in numerous studies. [35],[36] It is interesting to note that visual acuity prior to SO removal was not found to be a statistically significant predictor of surgical success. Before SO removal, the mean visual acuity in eyes that did not develop a re-detachment was 0.14 ± 0.16 versus 0.09 ± 0.16 (P = 0.14) in the eyes that did develop a re-detachment.

In our study, post-operative PVR was the cause of primary surgical failure in 4 eyes. Two of those four eyes had received the 360° laser and the remaining 2 eyes had not.

Postoperative causes of re-detachment

Only 10/22 eyes that had a retinal re-detachment came in for secondary intervention and the rest were lost during the follow-up. Five of the 10 eyes re-operated on had received the 360° laser during the primary procedure. Two eyes with 360° laser had severe PVR and needed the placement of an encircling band. Two eyes had a residual posterior hyaloid that was removed, and the retina re-flattened. The only case that had a recurrence specifically due to the laser treatment was the one eye that developed a break at the edge of the laser barrage. In this eye, an extra row of 360° laser was applied after re-flattening of the retina. All eyes that were re-operated on got SO as a tamponade, and all retinas remained attached 3 months after the oil was removed. According to our study, no difficulties were encountered when re-operating on eyes with prior 360 -versus no 360° laser treatment.

Anisocoria and 360° laser

In our study, the difference between the pupillary diameter of eyes that received the 360° laser treatment and the other healthy eye was 1.18 ± 0.95 mm. The difference in diameter of the pupils that did not receive the laser treatment when compared to their other healthy eyes was 0.87 ± 0.87 mm (P = 0.05). This clearly shows that there is a statistically significant relationship between the application of 360° laser and the postoperative pupil size. Some papers have recommended that when applying laser in the periphery of the retina we should try to avoid the long and short ciliary nerves in order to decrease the likelihood of postoperative internal ophthalmoplegia. None of these studies had directly compared the outcomes of treating versus not treating over the areas of the ciliary nerves. [17],[33] In our study, we did a complete 360° laser barrage, including the horizontal and vertical meridians. To our knowledge, this is the first study demonstrating the effect of 360° laser on postoperative anisocoria.


  Conclusion Top


Prophylactic intraoperative 360° laser retinopexy did not have a role in the prevention of retinal re-detachment after primary retinal repair with 23-G transconjunctival vitrectomy. The only adverse effect associated with 360° laser retinopexy is postoperative anisocoria.

Preoperative poor prognostic factors on surgical outcomes are preoperative visual acuity of HMBP or worse and a longer duration of the retinal detachment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]


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International Ophthalmology. 2018;
[Pubmed] | [DOI]



 

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