|Year : 2019 | Volume
| Issue : 1 | Page : 16-20
Needle subretinal fluid drainage assisted pneumatic retinopexy for primary rhegmatogenous retinal detachment
A Raghuram1, K Divya1, V Narendran2, M Raaja Ganesh1, VR Saravanan2
1 Department of Ophthalmology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
2 Department of Vitreoretina, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
|Date of Web Publication||14-Aug-2019|
Dr. K Divya
Department of Ophthalmology, PSG Institute of Medical Sciences and Research, Coimbatore - 641 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Purpose: Pneumatic retinopexy (PR) continues to remain an important technique in the management of rhegmatogenous retinal detachment (RRD). We describe the results of a novel surgical technique of PR with subretinal fluid (SRF) drainage in this retrospective, nonrandomized case series. Subjects and Methods: Medical records of patients with primary RRD who underwent PR with SRF drainage and had been followed up for 6 months or more were reviewed. The procedure involved transconjunctival cryotherapy followed by drainage of SRF using a 26G needle and intravitreal injection of perfluoropropane. Outcome data measured included final visual acuity, anatomical success with single surgical procedure, surgical complications, and need for subsequent procedures. Results: Out of the 12 patients, there were 7 males and 5 females. The 12 patients aged in range from 24 to 64 years (average - 43 ± 15.55 years). Average duration of follow-up was 10 ± 3.56 months (range: 6–14 months). Eleven eyes achieved anatomical reattachment of the retina with a single procedure (91.6%). Redetachment was noted in one patient who was successfully treated with pars plana vitrectomy and scleral buckle.The final anatomical success rate was 100%. Visual acuity improved in all the eyes treated, and no major complications related to SRF drainage were encountered. Conclusion: PR with needle-assisted SRF drainage is a safe and useful technique for selected cases of primary RRDs with good anatomical and functional outcomes.
Keywords: Pneumatic retinopexy, retinal detachment, subretinal fluid
|How to cite this article:|
Raghuram A, Divya K, Narendran V, Ganesh M R, Saravanan V R. Needle subretinal fluid drainage assisted pneumatic retinopexy for primary rhegmatogenous retinal detachment. Egypt Retina J 2019;6:16-20
|How to cite this URL:|
Raghuram A, Divya K, Narendran V, Ganesh M R, Saravanan V R. Needle subretinal fluid drainage assisted pneumatic retinopexy for primary rhegmatogenous retinal detachment. Egypt Retina J [serial online] 2019 [cited 2020 Mar 30];6:16-20. Available from: http://www.egyptretinaj.com/text.asp?2019/6/1/16/264519
| Introduction|| |
Pneumatic retinopexy (PR) is a minimally invasive surgical procedure useful in selected cases of primary rhegmatogenous retinal detachments (RRDs). Ever since its introduction by Hilton and Grizzard, PR has become a widely accepted alternative surgical technique to scleral buckle and pars plana vitrectomy for specific types of retinal detachments with comparable final anatomical results, less morbidity, and potential cost savings.,, The procedure involves transconjunctival cryopexy or laser photocoagulation of retinal breaks along with intravitreal injection of gas and appropriate patient positioning. Subretinal fluid (SRF) drainage is not usually performed in PR. The surface tension of the bubble closes the retinal break and prevents the bubble from passing into the subretinal space. With the retinal break closed, the retinal pigment epithelial pump removes the SRF. However, delayed resorption of SRF after PR has been reported by several authors., Loculated pockets of SRF in the macula can delay visual recovery and may affect the final visual outcome.,,
In this article, we present the results of a novel technique combining needle-assisted SRF drainage with PR for primary RRD. This approach combines the advantages of both PR and SRF drainage in conventional retinal reattachment procedures.
| Subjects and Methods|| |
This study was a retrospective, nonrandomized case analysis of patients with primary RRD who underwent PR with SRF drainage at a tertiary care center in South India. The medical records of these patients were reviewed. All patients had been followed up for a minimum duration of 6 months after the surgical procedure. Six months limit was chosen because the risk of redetachment is reported to be highest within the first 6 months.
The procedure was performed for new-onset primary RRD with breaks in the superior 8 o' clock hours (between 8 o' clock and 4'o clock) in patients older than 18 years of age after informed consent. The procedure was not performed in eyes with hazy media, glaucoma, proliferative vitreoretinopathy (PVR) Grade C, previous retinal surgery, or poor patient compliance. The Institutional review board approved the study protocol and the protocol complied with the tenets of the Declaration of Helsinki.
All patients had undergone complete ophthalmic evaluation including a detailed history, preoperative visual acuity, refraction, intraocular pressure measurement, and slit-lamp biomicroscopy. Indirect ophthalmoscopy with scleral indentation was performed to assess the number, size, and location of retinal breaks and macular status. Detailed retinal drawings had been drawn on standard retinal charts. All patients had undergone PR using the standard technique described below. Postoperatively, the patients had been followed at day 1, 1 week, 1 month, and 6 months. Wherever applicable, additional cryo/laser retinopexy was performed at the surgeon's discretion. New/missed peripheral breaks were treated by cryotherapy, while laser was performed for reopened breaks and persistent SRF. Additional procedures were performed around 1–2 weeks after the surgery.
Outcome data measured included final visual acuity, anatomical success with single surgical procedure, surgical complications, and need for subsequent procedures.
All procedures were performed under retrobulbar anesthesia. The retinal breaks were visualized and surrounded by transconjunctival cryotherapy. Localized conjunctival peritomy was performed in the quadrant where drainage was planned. After peritomy, one rectus muscle was bridled. The drainage site was marked with the help of bipolar cautery. The sclera was punctured with a ½-inch 26G needle, and the SRF was drained under the area of highest retinal elevation [Figure 1]. As the eye became quite soft after SRF drainage a pull on the bridled muscle helped in stabilizing the globe. This also helped in avoiding rotation of the eye and/or possible damage to the crystalline lens during the introduction of needle for gas injection. Around 0.6 cc of 100% perfluoropropane gas was injected via the superior pars plana 3–4 mm posterior to the limbus with the help of 26G needle in a brisk manner to achieve a single large bubble. With the injection site, uppermost and the needle vertical, moderately brisk injection of gas results in one single bubble at the needle tip. Conjunctiva was sutured with 8-0 vicryl. At the end of the procedure, indirect ophthalmoscopy was performed and perfusion of the optic nerve head was ensured in all patients. The patients were positioned such that the retinal breaks were uppermost to ensure tamponade by the injected gas bubble. Patients were asked to maintain the head position for 5–7 days.
|Figure 1: (a) Localized conjunctival peritomy with bridled rectus muscle, (b) subretinal fluid drainage site marked with cautery, (c) drainage of subretinal fluid with 26G needle, (d) intravitreal injection of gas via superior pars plana|
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| Results|| |
Out of the 12 patients, there were 7 males and 5 females. The 12 patients aged in range from 24 to 64 years (average - 43 ± 15.55 years). Average duration of follow-up was 10 ± 3.56 months (range - 6–14 months). None of the patients had phakic refraction >6 D. Nine had superior breaks (10:00–2:00) and three had temporal breaks (8:00–10:00). In patients with multiple breaks (5/12), all the breaks were clustered within the same quadrant. One patient (patient 12) had an additional inferior break in the attached retina. [Table 1] shows the summary of patient data and [Table 2] shows preoperative characteristics of the patients studied.
Out of the 12 eyes, 11 eyes achieved anatomical reattachment of the retina with a single procedure. Postoperative barrage LASER was done in five cases. Additional cryoretinopexy was done in one patient with peripheral new/missed break at follow-up. Resurgery was done in one patient (patient 11) who had severe vitreous condensation and a missed break. This patient underwent a scleral buckle along with pars plana vitrectomy and silicone oil infusion for persistent vitreoretinal traction.
Considering two Snellen lines of visual acuity change significant, vision improved in all the 12 patients studied. There were 10 patients with visual acuity of 20/200 or less preoperatively, while none of the patients had this acuity postoperatively [Table 3]. No major complications such as endophthalmitis, persistent elevated intraocular pressure, or cataract were encountered in our series. One patient had minimal choroidal hemorrhage at the drainage site in the inferotemporal periphery which resolved spontaneously. Patient 6 had inferior lattice with atrophic holes and a persistent shallow inferior RD postoperatively. She underwent additional laser retinopexy in the postoperative period and the detachment slowly settled.
| Discussion|| |
In this retrospective analysis, we found the rate of single surgery anatomical success after PR using the new technique to be 91.6%. This group included patients who received additional cryotherapy or laser in the postoperative period and maintained retinal reattachment throughout 6 months of follow-up. One patient who developed redetachment 1 month after surgery underwent additional reattachment procedure and had attached retina at the final follow-up visit. Hence, the final anatomical success rate was 100%.
Success rates following PR reported in the literature are found to vary in a wide range. Hilton and Tornambe reviewed the outcome of 1274 eyes in 26 published reports on PR performed between 1986 and 1989. The average single operation success rate was found to be 80% (range: 53%–100%) and average final success rate was 98% (range: 92%–100%). A comprehensive review on the surgical outcome of 4138 eyes that underwent PR over a 21-year period (1986–2007) has reported a single operation success rate of 74.4% and the final success rate of 96.1%. Few recent studies have reported lower rates of single operation success ranging from 59.5% to 69.6%.,, This has been attributed to the wider inclusion criteria including RRDs that generally have lower PR success rates such as multiple breaks in multiple quadrants and retinal breaks in the inferior clock hours. Pseudophakia, large retinal break, and/or PVR are reported to be significant predictors of treatment failure.
Cochrane Database Systematic Review 2015 comparing the relative efficacy of PR versus scleral buckle (with or without vitrectomy) for RRD found slightly less reattachment rate with PR (relative rate 0.89; 95% confidence interval: 0.77–1.02) and higher chances of recurrence (1.80; 95% confidence interval 1.0–3.24) but does not rule out no difference between the procedures. Eyes in the scleral buckle group have been reported to be more susceptible to choroidal detachment and myopic shift than eyes in the PR group. However, the authors have concluded that there is the absence of sufficient high-quality evidence from randomized controlled trials comparing the risks and benefits of PR versus scleral buckle. The choice of procedure depends on the clinical judgment, patient preferences and the surgeon's skill, and experience with each procedure. In spite of reports of variable success rates, PR has been shown to be a very useful, cost-effective method of RD repair with the potential to significantly reduce health-care burden. This is of utmost importance for a developing nation like ours.
Our high success rate can be attributed to the smaller sample size, meticulous preoperative examination, appropriate postoperative retinopexy, and the fact that most of our patients had classic indications for PR such as retinal breaks in the superior retina and absence of significant PVR.
Literature search on PR with drainage of SRF revealed only one similar study by Gündüz and Günalp in 1994. The authors have reported a series of thirty bullous retinal detachments treated with PR and SRF drainage using 25G diathermy needle. After 150°–180° limbal peritomy, drainage of SRF was performed under the area of highest retinal elevation first, and subsequently, cryotherapy and perfluoroethane injection were done. All the eyes were reattached after the first operation. In three (10%) eyes, new breaks with RD developed 2 weeks – 2 months after the initial procedure and were treated successfully with scleral buckling. The single operation success rate was 90% and eventual reattachment rate was 96.7%. Visual acuity improved in 80% of the eyes treated. They have concluded that anatomic and visual success rates after this procedure are comparable to conventional PR and that SRF drainage did not result in additional complications.
The authors have suggested that cryotherapy after drainage reduces risk of pigment epithelial dispersion into the vitreous and therefore lessens risk of PVR as well as avoids the need for steamroller technique. However, in our study, cryopexy was done before drainage of SRF. Adequate indentation of the sclera was achieved to produce enough cryopexy before SRF drainage in our series. In cases where the cryopexy was considered inadequate, it was repeated in the postoperative period. We observed no increased risk of PVR after this technique in our limited sample.
There are several advantages of PR with needle drainage of SRF over conventional PR. If bullous SRF extends almost to an attached macula, placement of bubble against the bullous detachment may push fluid into the macula and cause macular detachment. Steamroller technique has been suggested to prevent an iatrogenic detachment of macula, as well as iatrogenic detachment of an attached retinal break. However, with drainage of SRF before gas injection, the steamroller technique can be avoided and the theoretical possibility of PVR secondary to movement of SRF into vitreous is prevented.
One of the major reasons for failure of conventional PR is the presence of peripheral or missed retinal breaks which lead to reaccumulation of SRF and persistent retinal detachment. Drainage of SRF before gas injection allows better visualization of the peripheral fundus. This is useful in aphakic and pseudophakic eyes with multiple far peripheral breaks which have been reported to carry lower success rate after PR., However, recent studies have noted similar anatomical outcome in phakic as well as pseudophakic eyes., This has been attributed to an in-depth examination of the peripheral retina and treatment of breaks in all eyes, especially the nonphakic eyes.
A recent study comparing the outcome of PR as a primary procedure for RRD versus secondary procedure for recurrent RRD found a single operation success rate of 60% for primary intervention and 65.5% for secondary intervention. Age and preoperative and postoperative visual acuity were found to have significant association with single operation success rate. Progression of PVR was found to be the most common cause of failure, followed by nonresolving SRF, reopening of the original break, and formation of new breaks. Although the technique described in this article looks little invasive compared to conventional PR, it hastens resolution of SRF, is highly cost-effective, and obviates the need for a major surgical procedure.
This procedure can also be selected intraoperatively when scleral buckling techniques are likely to be hazardous or likely to have significant postoperative complications such as eyes with marked scleral thinning or the need for a bulky scleral buckle beneath the superior rectus muscle.
The rates of delayed SRF resorption after PR have been reported to vary between 4% and 12%.,, Although the SRF does get absorbed spontaneously over several months, persistent SRF can delay visual recovery and affect the final visual outcome. Drainage of SRF using a 26G needle as described in this article ensures rapid resolution of the detachment and visual recovery.
Patients with extensive lattice degeneration have been reported to be unsuitable for PR because of vitreoretinal adhesions and traction resulting in new breaks. However, in our study, six patients had lattice in the detached retina and three patients had lattice degeneration in the attached retina. Our results are consistent with the previous studies, in which lattice degeneration did not increase rate of surgical failure.,
Poor preoperative visual acuity has been reported to be associated with PR failure and poor final visual outcome by several authors and preoperative visual acuity has been suggested as one of the factors which predict visual recovery., In contrast to these studies, worse initial visual acuity was not associated with adverse visual outcome in our series.
Our choice of long-acting perfluoropropane for intravitreal injection was based on its availability. The bubble expands slowly that allows for equilibration of intraocular pressure during the first few days following injection. Perfluoropropane also eliminated the need to reinject gas if a new break develops.
We did not encounter complications such as intraocular hemorrhage or vitreoretinal incarceration related to SRF drainage in our series. It has been argued that cryotherapy may cause vascular congestion of the choriocapillaris and that SRF drainage should not follow cryotherapy. However, we found that SRF drainage after cryotherapy was not associated with increased risk of intraocular hemorrhage or adverse visual outcome. Our observations are in line with other published studies. The 26G needle used for SRF drainage results in a very narrow transscleral tract and therefore the risk of vitreoretinal incarceration is minimal. Furthermore, localized conjunctival peritomy minimizes the conjunctival damage as compared to scleral buckling.
The limitations of our study include its limited sample size and retrospective design. Subgroup analysis could not be performed owing to the small sample size. Furthermore, we have not examined the relative efficacy of primary vitrectomy and/or scleral buckle versus PR with SRF drainage which would be useful, but beyond the scope of this article.
| Conclusion|| |
PR with needle-assisted drainage of SRF is a safe and useful technique for selected cases of primary RRD. Conjunctival damage is less and minimal additional instrumentation is required. This technique has many advantages over conventional PR and good anatomic and visual outcomes can be achieved with less morbidity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]