|Year : 2015 | Volume
| Issue : 2 | Page : 81-86
Determinants of effectiveness of scleral buckling as a primary care surgery in rhegmatogenous retinal detachment among underprivileged cases unable to afford vitrectomy
Padma B Prabhu, Raju Kuzhupally Vallon
Department of Ophthalmology, Government Medical College, Kozhikode, Kerala, India
|Date of Submission||21-Sep-2013|
|Date of Acceptance||18-Nov-2014|
|Date of Web Publication||7-May-2015|
Padma B Prabhu
19/2313, 'Swathi', Chempaka Housing Colony, Pottammal, Kozhikode - 673 016, Kerala
Source of Support: None, Conflict of Interest: None
Background: The purpose of this study was to determine the role of scleral buckling in the present era of pars plana vitrectomy and to evaluate the factors determining the outcome of buckling in terms of anatomical attachment of retina, visual recovery, and complication rate. Aims: To analyze the surgical outcome of uncomplicated rhegmatogenous retinal detachment (RRD) after scleral buckling and to assess the factors predictive of good outcome in the study group. Design: Retrospective chart review. Materials and Methods: Patients who underwent scleral buckling for primary RRD during the period of 2 years from June 2010 were included. The details regarding age, gender, laterality, presenting complaints, duration of the disease, coexisting systemic disease, and ocular risk factors were noted. Details of ocular examination, best corrected visual acuity (BCVA), intraocular pressure (IOP), and B scan ultrasonography findings were recorded. Follow up data of these patients for a period of four months after buckling procedure was collected. Statistical analysis was performed. Results: The type of RRD whether fresh or old, subclinical, subtotal or total, macular detachment, or the duration of onset did not affect the final outcome. Cataract surgery with vitreous disturbance was associated with poor anatomical and visual recovery. Milder cases of trauma had good prognosis. Lower pre-operative IOP and poorer pre-operative visual acuity were predictors of poor functional recovery. The technique of surgery did not influence the results. Conclusion: This surgical technique remains a choice for the underprivileged cases that are unable to afford high cost retinal procedures.
Keywords: Anatomical success, complications, detachment, rhegmatogenous retinal outcome, scleral buckling
|How to cite this article:|
Prabhu PB, Vallon RK. Determinants of effectiveness of scleral buckling as a primary care surgery in rhegmatogenous retinal detachment among underprivileged cases unable to afford vitrectomy. J Clin Ophthalmol Res 2015;3:81-6
|How to cite this URL:|
Prabhu PB, Vallon RK. Determinants of effectiveness of scleral buckling as a primary care surgery in rhegmatogenous retinal detachment among underprivileged cases unable to afford vitrectomy. J Clin Ophthalmol Res [serial online] 2015 [cited 2023 Mar 24];3:81-6. Available from: https://www.jcor.in/text.asp?2015/3/2/81/156590
The approach to rhegmatogenous retinal detachment (RRD) is complex, often based on the surgeon's choice. Scleral buckling, the conventional surgery for RRD is being replaced by vitreo-retinal procedures as the first-line management of RRD.  Parsplana vitrectomy needs costly equipments, wide field surgical viewing systems and well-trained surgeon specialized in these techniques. However, these facilities are not freely available and accessible to all, even those living in urban areas. Scleral buckling is a low cost, extra-ocular surgical technique independent of expensive and advanced infrastructure. This study evaluates the present role of scleral buckling as the first line management of RRD and to analyze the factors predictive of surgical outcome after scleral buckling.
| Materials and Methods|| |
The medical records of patients who underwent scleral buckling for primary RRD during the period from June 2010 to May 2012 were analyzed retrospectively. The study was approved by the institutional ethics committee. RRD in young <20 years of age, RRD associated with tractional retinal detachment (RD), RRD with dense vitreous hemorrhage precluding fundus view, retinal dialysis, giant retinal tear, posterior breaks, grade 3 and/or 4 prolifrative vitreoretinopthy (PVR), RRD due to severe ocular trauma and globe rupture, RRD associated with familial vitreo retinal disorders, residual RD and redetachment were excluded. Cases with incomplete hospital data and follow-up were also excluded. The collected data included demographics of RRD patients, the clinical features of the RD in these patients and the assessment of the retina following scleral buckling for a period of 4 months after surgery. The information regarding age, gender, laterality, presenting complaints, duration of the disease, coexisting systemic disease, and ocular risk factors (myopia, trauma, cataract surgery, and peripheral retinal degenerations) were noted. Details of ocular examination, best corrected visual acuity (BCVA), intraocular pressure (IOP), and B scan ultrasonography findings were recorded. Anterior segment, fundus examination, IOP, and BCVA were noted at each follow-up visit after scleral buckling. Success was defined in terms of anatomical attachment, functional improvement, and absence of at least one symptomatic complication other than defective vision at the end of four months follow-up. Each factor was given a value score and the values were added to get four subgroups. Group A with a total score of 3 was considered to have an excellent prognosis. Group B (score 2) had good outcome both in terms of anatomical and functional success; group C (score 1) had poor outcome and group D (score 0) had worst results. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 17.0. Chi-square test was used for univariate analysis.
| Results|| |
In this study, 77 cases fulfilled the criteria for uncomplicated primary RRD. There were 57 males (74%) and 20 females (26%). The mean age of the patient was 57.01 (standard deviation, SD ± 10.056); range 30-74 years. Thirty-one patients (40.3%) belonged to the age group 60-69 years. Five cases (6.5%) were bilateral. Right eye was affected in 49 (63.6%) cases and left eye in 28 cases (36.4%). The duration of onset of symptoms ranged from 1 day to 330 days; mean 39.48 (SD 57.092), 24 patients (31%) had history lasting for 15-30 days. Symptoms prior to the occurrence of defective vision included flashes only (n = 7), floaters only (n = 4), both flashes and floaters (n = 29), and eye pain (n = 2). Thirty-two cases had no other symptoms apart from defective vision. Defective vision involved the peripheral field in 11 cases; central field in 2, and both fields in 62 cases. Two patients had good vision and RD was detected incidentally.
Eighteen patients had total RD (23.4%); 56 cases were subtotal (73%), and three cases, subclinical (49%). Flap tear was the cause in 63 (82%) cases. Atrophic hole resulted in RD in five cases (7%). No rhegma was identified in nine cases (12%). Superotemporal breaks 41 (53%) were the commonest followed by inferotemporal (n = 12), superonasal (n = 3) and inferonasal (n = 1). Thirty cases had secondary breaks (39%). The mean number of break was 0.81 ± 1.335, range 1 to 7. Fresh RD accounted for 74% (57 cases). Seventy-six percent of the cases were superior RD (41 cases). Macula was detached in 68 patients (91%). Among the old RDs, demarcation line was noted in eight cases, atrophic retina in five cases, and mild PVR in seven cases. Anterior vitreous cells and pigments were present in 88% (n = 68). Total posterior vitreous detachment (PVD) was seen in 62% (n = 48) and partial PVD in 34% (n = 26). Mild vitreous hemorrhage was noticed in six cases. One of them had history of trauma. Lattice without hole was the most common peripheral retinal degeneration (n = 29; 38%). Other peripheral retinal degenerations were lattice with hole (n = 14), white without pressure (n = 13), snail track degeneration (n = 5), and retinoschisis (n = 2). Peripheral retinal degeneration was not seen in 13 eyes. The other predisposing factors were trauma (n = 7), cataract surgery (n = 31), and myopia (< 6D = 26; > 6D = 8). Twenty-two eyes were pseudophakic with posterior chamber intraocular lens, four eyes were pseudophakic with anterior chamber intraocular lens and five eyes were aphakic. Cataract was noted among nine cases. The lens remained normal in the rest 36 eyes.
Sixty-seven cases (86.7%) had BCVA <10/200 at the time of presentation. There were three cases with BCVA 20/20-20/60, four eyes with BCVA 20/60-20/200, and three cases with BCVA 20/200-10/200. The mean IOP was 11.323 (SD = 3.084); range 4.0-17.3 mmHg. Mean IOP of the other eye was 15.482 (SD = 2.936); range 10.6-20.6.
Segmental circumferential buckling with No 277 silicone tyre combined with encirclage using No 240 silicone band was done in 69 cases. Among eight patients, the retinal tyre No 277 was used for 360 0 encirclage. Cryotherapy around the break was done in 21 cases; subretinal fluid (SRF) drainage in 29 cases; and both Cyro and SRF drainage in 17 cases.
After scleral buckling, retina was attached in 60 cases (78%). Out of the 17 cases with no retinal attachment, 13 patients were taken up for vitrectomy, four cases were not willing for a second surgery. More than two line visual improvement in visual acuity was noted in 47 cases (61%). Thirteen patients had no visual improvement in spite of an attached retina. The post-operative BCVA was as follows; 20/20-20/60 n = 20 (27%); 20/60-20/200 n = 11(15%); 20/200-10/200 n = 17(23%); and 10/200-perception of light (PL) n = 17 (23%).
No significant symptomatic complications were found among 80.5% (n =62) during the 4-month follow-up. The list of complications is given in [Table 1]. Unplanned subretinal fluid drainage was the commonest intra-operative complication (n = 12). Shallow anterior chamber (5), persistant hypotony (4), choroidal detachment (4), scleritis (4), and discharge (4) were the common early complications. PVR was the most common late complication (n = 29). The symptomatic complications other than defective vision were diplopia, suture protrusion, scleritis, discharge, metamorphopsia, anterior segment ischemia, neovascular glaucoma, and hemolacria.
Chisquare test was used to study the association between the demographic prolife, clinical features, risk factors, and the technique of surgery with the surgical outcome [Table 2] and [Table 3].
| Discussion|| |
Rhegmatogenous RD constitutes a very small percentage of reported causes of blindness and low vision globally.  Even though the incidence of RRD is less than that of cataract and glaucoma, the visual impairment following RRD is of graver consequence than the other diseases. The sudden onset of gross defective vision, the need for multiple surgeries, surgical inconvenience, financial burden, delay in post-operative visual recovery, long follow-up, subnormal visual acuity after the procedure, and high complication rate makes management of RD tedious and tiresome. Vitrectomy is emerging as the primary approach to RRD.  Setting up of facilities for vitrectomy is expensive, requiring wide field viewing systems, advanced technology machinery and trained competent surgeon and ancillary staff. There are only few centers in India where these facilities are available free of cost. The main obstacle faced by people even in urban areas is the lack of access to good quality and affordable eye care services. Scleral buckling is a cost-effective alternative to vitrectomy in the primary management of RRD. This study analyses the outcome of scleral buckling in uncomplicated RRD and the key factors determining the surgical results. An attempt is made to ascertain whether scleral buckling can be suggested as a primary care surgery in the management of uncomplicated RRD. The cases were grouped based on the demographic data, clinical features of RD, risk factors behind development of RD in these cases and the type of surgery done in each particular case. The age of the patient, laterality, gender, or eye involvement had no effect on the anatomical attachment, functional success, or complication rate. The type of RRD, presence of rhegma, the quadrant of primary break, and presence of secondary breaks did not alter the retinal attachment rate or functional recovery. It did not affect the complication rate or the final score. This is in contrast to the findings of Mitry D et al., Khan et al., and Heusen et al.,, According to Khan et al., late presentation, macular detachment, and higher grades of PVR were associated with poorer outcome.  According to Heusen et al. negative effect of longer duration of symptoms was significant only among phakic RRD. The visual outcome was poor among those with total RRD, RRD with central detachment those with a chain of breaks.  Macular detachment was observed among 90.7% of the RRDs. There was no statistically significant difference among the macula on and off subgroups in retinal attachment (P = 0.303), visual recovery (P = 0.754), and complication rate (P = 0.327). The macular involvement did not influence the final outcome in our study. This is in concordance with the findings of Thelen et al. in the Munster Study on Therapy Achievements in Retinal Detachment (MUSTARD).
study, the largest ever published data on RD overall.  Salicone A et al. reported poor prognosis among cases with macular detachment.  All the three cases of subclinical RRD (without involvement of macula) showed excellent results with stable visual functions. Long standing RRDs are characterized by the presence of demarcation line, atrophic changes in the retina, cysts and proliferative vitreoretinopathy. Among 20 cases with features of old RD like demarcation line, atrophic retina and grade 1 or 2 PVR, 15 cases were attached with 11 (55%) patients recovering vision of more than two lines Snellen visual acuity. Sixteen (16/20).
Sixty cases (80%) had no symptomatic complications. Thus, the outcome after scleral buckling was independent of the duration of the disease. According to Mitry et al. older RRD had greater failure rate. PVR of any degree and involvement of more clock hours of retina increased the chance of failure.  In this series, the duration of symptoms was found to have no effect on the final outcome. When attachment rates were compared, 76.2% of RRD's with duration less than 7 days were attached after the procedure. This was comparable with those with longer duration (70.0%). Similarly, 61.9% of RRD's with duration less than 7 days and 60% of those with duration of more than 1 week regained more than two line improvement in visual acuity after buckling. The complication rates were also comparable (76.2% and 60%, respectively, in each group). These findings were statistically significant. (P = 0.046). Out of 11 cases with duration more than two months, 64% had good results. Thirteen percent of cases with attached retina and 18% with detached retina after buckling had duration of disease more than two months. This suggests that scleral buckling can be undertaken as a primary procedure even in patients with longer duration of symptoms. Salicone A et al. have reported that duration of macular involvement of up to 30 days was of no prognostic value following scleral buckling.  Khan M.T et al. has noted that late presentation did not influence the anatomical attachment but visual acuity was poor.  The pre-existing risk factors considered were presence of myopia, presence of peripheral retinal degeneration, cataract surgery, and trauma. The presence of peripheral retinal degeneration or myopia did not alter the retinal attachment or functional recovery. It did not affect the complication rate or the final score. Myopia of more than 6 diopter (D) was found only among eight cases. This may be due to the fact that high myopes are well screened for peripheral retinal degeneration with retinal thinning and widespread use of prophylactic barrage laser photocoagulation is effective in preventing development of RD in such patients.  Similar findings were described by Thelen U et al. In their series, the incidence of myopia more than -3D was less than 25% and the success rate among moderate myopes (2D to 8D) was 86.70%. This was more than among low degrees of myopia. In our study, the anatomical success and visual recovery was more among those with myopia less than 6D. However, this finding was not statistically significant.
Intraocular surgery as a risk factor was seen in 35.8% (31 cases). Pseudophakic RD was more common than aphakic RD. Association of intraocular surgery with RRD has been estimated to be 10-40% by Li et al.  Presence of anterior chamber intraocular lens (ACIOL) and aphakia were associated with reduced success rate. Though anatomical attachment was seen in five out of eight cases with vitreous disturbance in terms of presence of ACIOL and aphakia, the visual recovery was noted only in two cases (P = 0.071). However the incidence of complication or the final score was not affected. According to Haritoglo C et al. anatomical success was better among phakics than pseudophakics.  Thelen U et al. did not find any relation between outcome and lens status.  The results were similar among phakics, pseudophakics, and aphakics.
There were seven patients with history of trauma prior to the onset of RRD. These were mild injuries with minimal damage to the eye and adnexa. One of them had mild vitreous hemorrhage. All the seven cases had attached retina (P = 0.140) and more than two line improvement in visual acuity (P = 0.027) following the surgery. The presence of trauma did not increase the chance of symptomatic complications. It had no effect on the final score. This can attributed to early referral in these cases. Traumatic RRD is associated with higher degrees of PVR and poorer outcome in literature. , However, in our study, mild trauma had good prognosis. Presence of mild trauma is not a contraindication for scleral buckling.
Total RD was associated with low IOP (P = 0.042). The IOP of the fellow eye was also low (P = 0.073). IOP values were not different among those with fresh or old RRD. Presence of trauma, cataract surgery, or macular detachment was not related to low IOP values. Pre-operative visual acuity was lower among patients with lower IOP (P = 0.004). Among those with lower IOP, functional success was less (P = 0.055), and complications were more (P = 0.003). Retinal attachment rate was not altered (P = 0.190).
Pre-operative visual acuity did not correlate with anatomical success (P = 0.191) or complications (P = 0.133), but it correlated with functional success (P = 0.056). Those with poorer pre-operative vision had less visual recovery. There was no statistically significant correlation between pre-operative and post-operative visual acuity values (P = 0.568). The post-operative visual acuity was better among those with attached retina (P = 0.00). However, it did not determine the absence of symptomatic complications (P = 0.133). Better pre-operative or baseline visual acuity was associated with better outcome by Salicone A et al. However, no such difference was noted in other studies. 18,19
Anatomical attachment after the primary procedure was seen in 77.9% of the cases. The surgical results vary from 80.78% (Mitry D et al.) to 98% (Gerding H et al.).  Vision more than 20/200 was noted among 41.4% cases. This is comparable to the results of Byanju R N et al. (39.1%) and Khan M T et al. (28.57%). ,,
The final outcome after buckling was not dependent on the method of encirclage, and whether cryotherapy or subretinal fluid drainage was done or not. This is in concordance with the results of Mitry D et al., Thelen U et al. and Soni C et al. ,, Application of cryo around the break was done in limited cases to reduce the chance of proliferative vitreo retinopathy.  The incidence of PVR was not statistically significant among those who underwent cryotherapy around the break. SRF drainage was associated with less symptomatic complications (P = 0.043). SRF drainage had positive association with the anatomical success in the study by Feltgen N et al.  No significant difference occurred in our study.
| Conclusion|| |
In our series, the type of RRD, involvement of macula or the duration of onset di d not affect the final outcome, in terms of anatomical attachment, functional recovery, and complication rate. Among the risk factors, cataract surgery with vitreous disturbance was associated with poor anatomical and visual improvement. Milder cases of trauma had good prognosis. Lower pre-operative IOL and poorer pre-operative visual acuity were associated with poor visual recovery. Lower IOP increased the chance of symptomatic complications. Though a myriad of complications were noted in the study, most of them were asymptomatic and could be managed conservatively. The technique of surgery did not alter the outcome. Thus, scleral buckling represents a surgical technique worth being trained and performed as a primary care surgery for RRD especially in peripheral eye hospitals when the patients cannot afford high cost surgery.
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[Table 1], [Table 2], [Table 3]