|Year : 2015 | Volume
| Issue : 2 | Page : 50-53
Twin-light-assisted scleral buckle for primary rhegmatogenous retinal detachment
Department of Ophthalmology, Assiut University Hospital, Assiut, Egypt
|Date of Web Publication||7-Nov-2016|
Department of Ophthalmology, Assiut University Hospital; Tiba Hospital for Eye Surgery, Assiut
Source of Support: None, Conflict of Interest: None
Aims: Our aim is to evaluate the use of BIOM-3 (Oculus, Germany) and 27-gauge Eckardt twin-light chandelier endoillumination (DORC, Netherland) as an alternative to indirect ophthalmoscope. Settings and Design: A prospective, interventional case series study was conducted in T.E.H. (Private Practice), Assiut, Egypt. Subjects and Methods: Twenty patients (Twenty eyes) complaining of primary rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy ≤ Grade B from January 2013 to April 2014. All patients underwent 27-gauge twin-light chandelier endoillumination for retinal break localization. Break localization was followed by cryopexy (Cryomatic Cryo Console, Keeler Ltd., UK) and standard scleral buckling under surgical microscope. Anatomical and functional outcomes were evaluated at the end of 6 months. Results: Anatomical success (attachment of retina) was achieved in 18 (90%) of twenty eyes. All these eyes remained attached at the end of 6 months. Significant improvement in mean best-corrected visual acuity was achieved at the end of 6 months follow-up 0.05 ± 0.46 preoperatively compared with 0.5 ± 0.14 postoperatively (P = 0.023). Conclusion: Twin-light-assisted scleral buckling for primary RRD is a better alternative to classic surgery with indirect ophthalmoscope.
Keywords: Endoillumination, retinal break, retinopexy
|How to cite this article:|
Ibrahim W. Twin-light-assisted scleral buckle for primary rhegmatogenous retinal detachment. Egypt Retina J 2015;3:50-3
| Introduction|| |
Primary rhegmatogenous retinal detachment (RRD) is usually managed either by conventional scleral buckling (SB), pneumatic retinopexy, pars plana vitrectomy, or a combination of these procedures. 
SB was first performed as a technique to repair RRD by Custodis in 1949 and was popularized in the 1950s. The underlying principle in SB is approximation of neurosensory retina with the retinal pigment epithelium by compression of the globe wall; thus, preventing passage of liquid vitreous into the subretinal space and pigment epithelial pump will remove the subretinal fluid. 
Thereafter, vitrectomy was advocated for patients with complex retinal detachments such as giant retinal tears or higher grades of proliferative vitreoretinopathy (PVR). With increasing experience and advances in surgical instrumentation, vitrectomy is now being used more frequently in the primary management of retinal detachments. Despite comparable visual outcomes with SB in both phakic and pseudophakic eyes in comparison to vitrectomy, it is declining in popularity among vitreoretinal surgeons. 
The success of conventional SB surgery depends on accurate localization of retinal break(s) and subsequent closure, using a buckle sutured to the scleral surface. Accurate localization of retinal breaks during surgery is highly dependent on the skill of the surgeon with indirect ophthalmoscopy. 
During the past several years, a variety of chandelier lighting systems were manufactured, including a single-fiber system available in 25-gauge and 27-gauge formats and a separated 2-fiber system in a 27-gauge or 29-gauge model. Advantages of chandelier light include bimanual manipulation during surgery, self-scleral indentation, controlled vitreous base shaving, and bimanual membrane dissections in difficult cases as diabetic tractional retinal detachment or PVR. ,,,
In our study, we exploited the advantages of chandelier endoillumination, wide-field viewing system, and surgical microscopy for doing scleral buckle for primary retinal detachment cases as an alternative to conventional procedure utilizing indirect ophthalmoscope.
| Subjects and Methods|| |
This was a prospective, interventional case series of twenty consecutive patients who presented to T.E.H., Assiut, Egypt, from January 2013 to April 2014 with primary RRD and PVR grade < Grade C. A written informed consent from all patients was taken. Patients unwilling to participate, younger than 18 years, history of ocular trauma associated retinal diseases, and detachments with PVR ≥ Grade C were excluded from the study. Baseline characteristics including patient age, sex, duration, and characters of detachment, preoperative best-corrected visual acuity (BCVA), lens status, and PVR grade were recorded.
A 360° peritomy and extraocular muscle bridling were followed by placement of 27-gauge Eckardt twin-light chandelier in inferotemporal quadrant (as in our study, all cases had a superior retinal breaks with variable number and distribution). Under high microscopic magnification and through BIOM-3 (Oculus, Germany), retinal periphery was examined meticulously till ora serrata by the use of twin-light which could be adjusted and directed to area examined along with easy self-indentation by the other free hand. Once the retinal break was localized using indentation, cryoretinopexy (Cryomatic Cryo Console, Keeler Ltd., UK) was performed. Chandelier endoillumination was then removed, and sclerotomy was closed using 7/0 vicryl. Conventional buckling was then performed using silicon-based scleral buckle and encirclage, and height of buckle was adjusted according to break buckle relationship under observation of indirect ophthalmoscope. Drainage of subretinal fluid was done on basis of retinal detachment distribution through full thickness radial sclerotomy and choroidal penetration, followed by scleral closure by 7/0 vicryl sutures. Closure of peritomy was done by 7/0 vicryl sutures [Figure 1]. No injection of air or gas was needed in all cases. Single case of scleral buckle application without drainage of subretinal fluid was done (a case of shallow superotemporal RRD).
Patients were assessed for anatomical retinal attachment and visual acuity change at 1 day and 1, 3, and 6 months. Statistical analysis was performed using the SPSS version 17.0 (SPSS, Chicago, Illinois, USA). Paired t-test was used to evaluate significant change in BCVA. P < 0.05 value was considered as statistically significant.
|Figure 1: Twin-light-assisted scleral buckling surgical steps, (a) placement of twin-light chandelier (b) detection of the retinal break with wide-field visualization (c) cryoretinopexy (d) application of proper scleral buckle and drainage of subretinal fluid|
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| Results|| |
Mean age of twenty patients was 46.1 ± 7.04 years (range, 34-61); 12 were males and 8 females. Fourteen eyes (70%) were phakic, 5 (25%) were pseudophakic, and 1 (5%) was aphakic. All retinal detachment cases were associated with retinal breaks in superior quadrants with variable amount of retinal breaks [Table 1]. Eleven cases (55%) had PVR Grade B while 9 cases (45%) had PVR Grade A. Initial retinal attachment could be achieved in 18 of 20 eyes (90%). Two eyes (10%) required further re-operation with 23-gauge pars plana vitrectomy and silicone oil injection, which had failed SB. Recurrence of retinal detachment could be attributed to the development of PVR. Retina remained attached in all eyes at 6 months. Mean pre- and post-operative BCVAs were 0.05 ± 0.46 and 0.5 ± 0.14 (P < 0.023). No patient developed intraocular pressure rise, iatrogenic cataract, endophthalmitis, scleral perforation, buckle-related complications, or sclerotomy site complications.
| Discussion|| |
The success of SB surgery for primary RRD depends on two important factors that are accurate localization of the retinal break and wide clear field of view of the retinal periphery. In the traditional technique, SB was done by wearing headband of indirect ophthalmoscope and viewing the retinal periphery with auxiliary lens (+20 D-noncontact lens). This method has many disadvantages such as small, inverted fundus image, difficult visualization through small pupil, increased possibility of missing small retinal breaks, heaviness of indirect ophthalmoscope, and uncomfortable position of the surgeon.
However, with the newer technique (twin-light chandelier and BIOM for SB surgery) there are many advantages over the traditional one such as clear direct retinal image that can be enlarged even with small pupil, easier detection of retinal breaks, wider angle of viewing, and better illumination and ease operation for the surgeon.
To avoid the possible risks of surgical complications such as vitreous wick from scleral wound, endophthalmitis, and light toxicity from the chandelier, we use small gauge fibers (Chandelier light 27-gauge) to prevent these complications. 
Furthermore, this technique avoids possible complications of vitrectomy such as increased risk of cataract progression, iatrogenic tears, complications of vitreous substitutes, and prolonged time of visual rehabilitation. 
| Conclusion|| |
Twin-light-assisted SB for primary RRD is a better alternative to classic surgery with indirect ophthalmoscope.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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