SUPPLEMENTAL SCLERAL BUCKLING FOR INFERIOR RETINAL DETACHMENT IN SILICONE OIL-FILLED EYES KAMAL A. M. SOLAIMAN, MD, SHERIF A. DABOUR, MD, FRCS (EDIN) Purpose: To evaluate the efficiency of treating selected cases of inferior retinal detachment in silicone oil-filled eyes using a supplemental scleral buckling with external drainage of subretinal fluid, versus performing a second vitreoretinal surgery and silicone oil endotamponade. Methods: A prospective interventional pilot study that was performed on silicone oil-filled eyes with inferior retinal detachment. Twenty-three eyes of 23 consecutive patients were alternatively distributed between 2 groups: Group A included 12 eyes treated with supplemental scleral buckling with drainage of subretinal fluid and without the removal of silicone oil, and Group B included 11 eyes treated with silicone oil removal, vitreoretinal surgery, and reinjection of silicone oil. The preoperative data included indications and details of primary vitreoretinal surgery, cause of retinal redetachment, subretinal fluid, grade of proliferative vitreoretinopathy, lens status, and the duration between primary vitreoretinal surgery and reoperation. The postoperative examination included the best-corrected visual acuity, retina status, proliferative vitreoretinopathy, silicone oil, and any reported complication. Follow-up examinations were scheduled at Day 1, weekly for 1 month, and monthly thereafter till the end of the follow-up period which extended for at least 2 months after silicone oil removal. Results: The average number of detached clock hours per eye was 2.7 in Group A and 2.4 in Group B, caused by a mean of 1.58 ± 0.80 break per eye in Group A and 1.48 ± 0.66 break per eye in Group B. The mean interval between the primary vitreoretinal surgery and the scleral buckling procedure in Group A patients was 2.83 ± 1.22 months (range, 1–5 months), while in Group B, the mean interval between the primary and the secondary vitreoretinal surgeries was 3.00 ± 1.61 months (range, 1–6 months). The mean operative time was statistically significantly (P , 0.05) shorter in Group A (38.7 ± 11.2 minutes) than in Group B (65.3 ± 15.1 minutes). The mean follow-up duration was 15.00 ± 3.22 months in Group A and 14.18 ± 2.99 months in Group B. After silicone oil removal, the retina was attached in 10 of the 12 eyes (83.3%) and redetached in 2 eyes (16.7%) in Group A, while in Group B, the retina was attached in 9 of the 11 eyes (81.8%) and redetached in 2 eyes (18.2%) after silicone oil removal. The mean logarithm of the minimum angle of resolution best-corrected visual acuity has improved from 1.82 ± 0.72 to 1.36 ± 0.52 in Group A patients (P . 0.05) and from 1.93 ± 0.74 to 1.55 ± 0.63 in Group B patients (P . 0.05) at the end of the follow-up duration. Conclusion: For selected cases of inferior retinal detachment in silicone oil-filled eyes, supplemental scleral buckling could be as effective as a second vitreoretinal surgery. Scleral buckling could offer a faster, less invasive, and better economic alternative to repeated vitreoretinal surgery for treatment of such cases. RETINA 34:1076–1082, 2014
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silicone oil bubble which is lighter than water and floats with positive buoyancy. This makes the subretinal fluid (SRF) accumulate in the inferior quadrants.3,4 Also, the bubble of silicone oil is rounded and this decreases the tamponade efficiency because part of the volume is used to form the meniscus instead of making contact with the retina.5 Another reason is that PVR has a propensity to occur in the inferior retina in silicone oil-filled eyes.5 The standard
ilicone oil is an established endotamponade in the treatment of complex vitreoretinal disease.1 The rate of recurrence of retinal detachment in silicone oil-filled eyes varies in different studies from 21.4% to 77%. The main causes of recurrence are open peripheral inferior retinal breaks, proliferative vitreoretinopathy (PVR), and intrinsic retinal contraction.2 Recurrence mostly affects the lower retinal quadrants and this is mainly because of the displacement of 1076
SCLERAL BUCKLING IN SILICONE-FILLED EYES SOLAIMAN AND DABOUR
surgical approach for such cases is repeated vitrectomy with silicone oil removal, elimination of tractions that usually includes relaxing retinotomy and retinectomy, use of perflourocarbon liquids, reattachment of the retina, and silicone oil or gas tamponade at the end of surgery.6,7 Some surgeons reported the use of scleral buckling combined with vitreoretinal surgery for treatment of such cases.8,9 Heavy silicone oil has been lately used with promising success as a tamponade for recurrent inferior rhegmatogenous retinal detachment (RRD) and PVR,10 although there are some concerns about its emulsification that necessitated its removal in a significant percentage of cases.11 However, in their study on the management of recurrent retinal detachment in silicone oil-filled eyes, Sharma et al2 had reported the absence of guidelines of reoperation on silicone oil-filled eyes in terms of surgical options, types of proliferation that cause recurrence of retinal detachment, and the anatomical and functional outcomes with different surgical techniques. This study was planned to study the efficiency of treating selected cases of inferior retinal detachment in silicone oil-filled eyes using a supplemental scleral buckling with external drainage of SRF, versus the standard of performing a second vitreoretinal surgery and silicone oil endotamponade. Patients and Methods This prospective interventional pilot study included 23 consecutive silicone oil-filled eyes with inferior retinal detachment. The study protocol adheres to the tenets of the Declaration of Helsinki (1996) and the regulations of the Medical Review Board of Zagazig University Hospital. After obtaining informed consent, eyes were alternatively allocated into 2 groups: Group A included 12 eyes treated with supplemental scleral buckling with drainage of SRF and without the removal of silicone oil, and Group B included 11 eyes treated traditionally with silicone oil removal, revitrectomy, and reinjection of silicone oil. The study exclusion criteria included eyes with PVR .C3, too posterior retinal breaks (inside the main vascular arcades), giant retinal break, previous scleral buckling, subretinal silicone oil, and eyes with any complication related to silicone oil. The retina was initially attached completely in all eyes in Group A and in Group B for From the Faculty of Medicine, Department of Ophthalmology, Zagazig University, Zagazig, Sharkeya, Egypt. None of the authors have any financial/conflicting interests to disclose. Reprint requests: Kamal A. M. Solaiman, MD, Faculty of Medicine, Department of Ophthalmology, Zagazig University, Zagazig, Sharkeya, Egypt; e-mail: [email protected]
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at least 1 month after the first surgery. Patients were prepared for the second surgery once recurrent inferior detachment was diagnosed. All eyes were subjected to complete ophthalmic examination including logarithm of the minimum angle of resolution best-corrected visual acuity (logMAR BCVA), cycloplegic refraction, slit-lamp biomicroscopy, and indirect ophthalmoscopy. The preoperative data included age, sex, indications and details of primary vitreoretinal surgery, cause of retinal redetachment, SRF, grade of PVR, the duration between primary vitreoretinal surgery and reoperation, and lens status. All surgeries in both groups were performed by the two authors of this article. In Group A patients, a 360° periotomy and isolation of the 4 recti muscles were performed followed by localization of the open retinal breaks and external retinal cryopexy, then placement of scleral sutures, external drainage of any significant SRF, and placement of an explant. Round silicone sponges 4 mm or 5 mm in inferior quadrants or a segment of silicone tire 287 with a 240 encircling band were used. Tires were used in 3 eyes (Cases 2, 7, and 11) as segmental buckles to support anteriorly located breaks and PVR, and the encircling buckle was completed with a Band 240. In Cases 2 and 7, tire was used for only 3 hours while it was used for 6 hours in Case 11. In 7 eyes (58.3%), 0.2 mLto 0.6 mL silicone oil was removed through 20-gauge pars plana sclerotomy to adjust the height of the scleral buckle without intraocular pressure (IOP) elevation. In Group B patients, after doing the standard three-port pars plana sclerotomies, silicone oil was removed through the upper sclerotomy by active suction. Triamcinolone acetonide was injected to visualize and remove any residual vitreous strands. Peeling of any epiretinal membrane was performed and perflourocarbon liquid was injected for internal drainage of SRF. Fluid–air exchange was performed and then silicone oil was injected again. Endolaser photocoagulation was applied around the open breaks under perflourocarbon liquid or under air. The postoperative examinations included the BCVA, retina status, PVR, silicone oil, and any reported complication. Follow-up examinations were scheduled at Day 1, weekly for 1 month, and monthly thereafter till the end of the follow-up period which extended after silicone oil removal for at least 2 months or occurrence of retinal redetachment within these 2 months. The primary outcome measure was the anatomical success which is defined as complete reattachment of the retina and closure of any open retinal break(s) with no residual SRF for at least 2 months after silicone oil removal. The secondary outcome measures are the change in the BCVA and any reported complication related to the procedure itself.
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Table 1. Preoperative Clinical Characteristics of Patients in Both Groups Variable
Group A
Group B
P
Male:female Mean age ± SD, years BCVA, mean logMAR Mean no. breaks per eye Mean clock hours of RD per eye Mean time after the first procedure, months
8:4 34.08 ± 16.03 1.82 ± 0.72 1.58 ± 0.80 2.7 ± 0.96 2.83 ± 1.22
7:4 40.91 ± 19.79 1.93 ± 0.74 1.48 ± 0.66 2.4 ± 1.03 3.00 ± 1.61
.0.05 .0.05 .0.05 .0.05 .0.05 .0.05
SD, standard deviation.
(Table 1). The average number of detached clock hours per eye was 2.7 ± 0.96 in Group A and 2.4 ± 1.03 in Group B, caused by a mean of 1.58 ± 0.80 break per eye in Group A and 1.48 ± 0.66 break per eye in Group B, with no statistically significant difference between both groups (P . 0.05). Retinal breaks in all eyes of the study were ,2 clock hours. The mean follow-up duration was 15.00 ± 3.22 months in Group A and was 14.18 ± 2.99 months in Group B, with no significant difference between both groups (P . 0.05). At baseline, four eyes in each group were pseudophakic with intact posterior capsules, and only one eye in Group A was aphakic with torn posterior capsule. The indications for primary vitreoretinal surgery in eyes of Group A and Group B were mentioned in Tables 2 and 4, respectively. In Group A, the indications for primary vitreoretinal surgery were primary RRD associated with PVR (six eyes), intraocular foreign body (IOFB) with RRD (two eyes), rupture globe (one eye), and penetrating trauma (one eye). In addition, one eye had IOFB with endophthalmitis and the other eye had macular hole. In Group B, the indications for primary vitreoretinal surgery were primary RRD associated with PVR (five eyes), IOFB with RRD (one eye), IOFB with
Statistical analyses of data were done using SPSS version 15 (SPSS Inc, Chicago, IL). Quantitative data were reported as mean ± standard deviation. Paired t-test was used to compare logMAR BCVA of each group at baseline and at the end of follow-up duration. A Student’s t-test was used to determine statistical significance between both groups. A P # 0.05 was considered to be significant. Snellen visual acuity was converted into logMAR values as developed by Ferris et al.12 The logMAR value of hand movement visual acuity was assigned +3.0 logMAR and counting fingers visual acuity was assigned +2.0 logMAR according to methods published by Holladay.13
Results The study included 23 consecutive eyes (23 patients) with inferior retinal detachment in the presence of silicone oil tamponade. Eyes were alternatively distributed between Group A (12 eyes) and Group B (11 eyes). No statistically significant differences (P . 0.05) were detected between both groups in the preoperative demographic, functional, and anatomical characteristics
Table 2. Demographic and Preoperative Data of Patients in Group A
Number Sex
Age, years
1
F
35
2 3 4 5 6 7 8 9
M M F M M F M M
22 48 28 50 17 42 48 15
10
F
62
11 12
M M
12 30
Indication for Primary Vitreoretinal Surgery RRD, posterior break, PVR IOFB, endophthalmitis RRD, PVR IOFB, RRD RRD, PVR RRD, PVR RRD, multiple breaks Macular hole Penetrating trauma, RRD RRD, posterior break, PVR Rupture globe, RRD IOFB, RRD
Duration Between the First and Second Surgery, months
Preoperative Vision
PVR Grade
4
1.8
C1
Phakic
2 3 4 5 2.5 1.5 2 3
0.6 3.0 1.0 2.0 3.0 1.8 2.0 1.8
— C2 C3 C3 — — C1 C2
Phakic Pseudophakic Phakic Pseudophakic Phakic Phakic Phakic Aphakic
4
2.0
C2
Phakic
2 1
1.8 1.0
— C2
Pseudophakic Pseudophakic
Lens Status
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SCLERAL BUCKLING IN SILICONE-FILLED EYES SOLAIMAN AND DABOUR Table 3. Operative and Postoperative Data of Patients in Group A
Scleral Buckle
Retina After Scleral Buckling
5 mm sponge 4 mm sponge Tire 287 + Band 240 4 mm sponge 5 mm sponge 5 mm sponge Tire 287 + Band 240 5 mm sponge 5 mm sponge 4 mm sponge Tire 287 + Band 240 5 mm sponge
Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached
Number 1 2 3 4 5 6 7 8 9 10 11 12
Complications
Retina After Silicone Oil Removal
Vision After Silicone Oil Removal
Follow-up, months
[IOP, cataract — [IOP, buckle infection — — — Cataract, silicone in AC Cataract, [PVR — [PVR — —
Attached Attached Attached Attached Attached Attached Attached Detached Attached Detached Attached Attached
1.0 0.6 1.8 0.8 2.0 2.0 1.0 1.8 1.1 2.0 1.6 0.8
12 21 19 18 14 17 15 16 12 11 13 12
AC, anterior chamber; [, increase.
endophthalmitis (one eye), and penetrating trauma (one eye). In addition, two eyes had macular hole and one eye had a combined tractional RRD. Recurrence of retinal detachment in the inferior retinal quadrants was because of open inferior peripheral retinal break(s) in all eyes of both groups and mild anterior PVR (#C3) in 8 eyes (75%) in Group A and 8 eyes (72.7%) in Group B. The mean interval between the primary vitreoretinal surgery and the scleral buckling procedure in Group A patients was 2.83 ± 1.22 months (range, 1–5 months), while in Group B, the mean interval between the primary and the secondary vitreoretinal surgeries was 3.00 ± 1.61 months (range, 1–6 months). Details of the scleral buckling procedures in Group A patients are shown in Table 3. Operative and postoperative details of Group B patients are shown in Table 5. The mean operative time in Group A was 38.7 ± 11.2 minutes that was statistically significantly lower than the mean operative time (65.3 ± 15.1 minutes) in Group B (P , 0.05). After silicone
oil removal, the retina was attached in 10 of the 12 eyes (83.3%) and redetached in 2 eyes (16.7%) in Group A. After silicone oil removal in Group B, the retina was attached in 9 of the 11 eyes (81.8%) and redetached in 2 eyes (18.2%). The mean logMAR BCVA has improved from 1.82 ± 0.72 to 1.36 ± 0.52 in Group A patients (P . 0.05) and from 1.93 ± 0.74 to 1.55 ± 0.63 in Group B patients (P . 0.05) at the end of the follow-up duration. Also, there was no statistically significant difference between the mean BCVA of both groups; both before and after surgery (P . 0.05). The BCVA improved by greater than two lines in five eyes in Group A and in four eyes in Group B, and remained unchanged in three eyes each in Group A and Group B. The BCVA did not deteriorate in any of the eyes of both groups. Iatrogenic retinal break occurred in 2 eyes (18%) in Group B and was treated intraoperatively by endolaser retinopexy. Cataract occurred in 3 eyes (25%) in
Table 4. Demographic and Preoperative Data of Patients in Group B
Number Sex
Age, years
1 2 3
M M F
24 26 55
4 5 6 7 8 9 10 11
F F F M F M M M
60 58 62 30 70 26 18 21
Indication for Primary Vitreoretinal Surgery Old RD, large break RRD, multiple breaks, PVR Combined tractional rhegmatogenous RD Macular hole Posterior break, PVR Myopic macular hole IOFB, endophthalmitis RRD, posterior break, PVR IOFB, RRD Penetrating trauma, RRD RRD, posterior break, PVR
Duration Between the First and Second Surgery, months
Preoperative Vision
PVR Grade
Lens Status
4 2 3
3.0 1.8 1.8
C2 C2 C3
Phakic Pseudophakic Phakic
4 5 2.5 1.5 2 3 4 1
1.5 1.0 1.5 1.3 3.0 2.0 3.0 1.3
— C1 C2 — C2 — C3 C1
Pseudophakic Phakic Phakic Phakic Phakic Pseudophakic Pseudophakic Phakic
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Table 5. Operative and Postoperative Data of Patients in Group B Number 1 2 3 4 5 6 7 8 9 10 11
Retina After PPV
Complications
Retina After Silicone Oil Removal
Vision After Silicone Oil Removal
Follow-up, months
Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached
Cataract — [IOP, cataract — — [IOP Cataract Cataract Retinal break [PVR, cataract Cataract
Attached Attached Attached Attached Attached Attached Attached Detached Attached Detached Attached
2.0 1.0 1.1 1.3 1.0 1.3 1.1 2.0 2.0 3.0 1.2
17 20 12 18 15 12 13 14 12 13 11
[, increase.
Group A and in 6 eyes (54.55%) in Group B (P , 0.05), and was removed by phacoemulsification and intraocular lens implantation either in a separate session or during silicone oil removal, without complications related to cataract surgery in all cases. Elevation of IOP in the early postoperative period occurred in 2 eyes (16.7%) in Group A and in 2 eyes (18.2%) in Group B, and was controlled by medications. Postoperative hypotony occurred in 1 eye (8.3%) in Group A and in 2 eyes (18%) in Group B. Buckle infection occurred in 1 eye (8.3%) and was controlled by medications. Ocular motility disturbances were observed in 2 eyes (16.7%) in group A, and in no eye in group B. Postoperative intraocular inflammation did not exceed the usual amount of postvitrectomy/scleral buckling inflammation in all eyes. Silicone oil in anterior chamber was detected in 1 eye (8.3%) in Group A. Epiretinal membrane formation was found in 3 eyes (25%) in Group A and in 2 eyes (18%) in Group B, and was surgically removed during silicone oil removal. Subretinal silicone oil migration was not observed in any of the eyes of both groups. Proliferative vitreoretinopathy has increased postoperatively in 2 eyes (16.7%) in Group A and in 1 eye (9%) in Group B. Retinal redetachment after silicone oil removal occurred in 2 eyes (16.7%) in Group A and in 2 eyes (18.2%) in Group B. Hypotony occurred after the removal of silicone oil in 2 eyes (16.7%) in Group A and in 2 eyes (18%) in Group B.
Discussion Since Custodis introduced scleral buckling as an effective treatment modality, it remains the “gold standard” in the treatment of RRDs. However, after Machemer’s introduction of vitrectomy as a useful technique in the management of complex vitreoreti-
nal diseases, the visual outcomes have been improved to approach, and in some cases exceed, those of the gold standard of scleral buckling.14 Also, the advent of silicone oil as an endotamponade in the treatment of complicated retinal detachment has led to more improvement in the success rate. The prognosis of inferior retinal detachment is usually guarded in both primary and recurrent cases.2,15 Recurrence of inferior retinal detachment after a vitreoretinal surgery and silicone oil tamponade is usually attributed to PVR2 and/or inadequate or unidirectional (superiorly directed) retinal tamponade with silicone oil, especially when a strict continuous posturing is not adhered to in the first few postoperative days.10 In the last few years, numerous investigators have published the outcomes of vitreoretinal surgery to treat recurrent inferior retinal detachment with fair anatomical and functional outcomes.2,8,9 However, the studies that investigated the use of scleral buckling for the treatment of recurrent inferior retinal detachment in silicone oil-filled eyes were very limited.16,17 Scleral buckling for inferior retinal detachment in silicone oil-filled eyes has many advantages. It increases the tamponading effect of silicone oil on the inferior retina, relieves the traction on the retina circumferentially and supports the retinal breaks.5 Also, by bringing the inferior retina closer to the silicone oil bubble, the scleral buckling will theoretically float the proliferative cells and the mediators of cellular proliferation away from the detached inferior retina in the upright position, and thus decreases PVR and consequently the rate of inferior retinal redetachment.18 Also, if recurrence occurs after scleral buckling, the support of the traction forces on the vitreous base and the retinal breaks is expected to add to the success of the subsequent vitreoretinal surgery.4,19 Based on the above mentioned data, we investigated
SCLERAL BUCKLING IN SILICONE-FILLED EYES SOLAIMAN AND DABOUR
the use of scleral buckling as a treatment modality for treatment of selected cases of inferior retinal detachment in silicone oil-filled eyes, and compared this group with another matching group of patients treated with the standard surgical approach in such cases; repeated vitreoretinal surgery and silicone oil endotamponade. Reoperation was a must in those eyes because detachment was recurrent and there were open retinal breaks continuous with the inferior retinal detachment, and a certain degree of PVR. If those eyes were left without treatment, they would be at risk of retinal detachment progression and that risk could greatly increase after the removal of silicone oil. Surgery on silicone oil-filled eyes calls for an additional surgical skill and meticulous planning.2 A precise adjustment of the height of the scleral buckle is essential to achieve adequate support of retinal breaks and to keep adequate internal tamponade effect by silicone oil without IOP elevation. In 7 eyes (58.3%) of Group A, 0.2 mL to 0.6 mL of silicone oil was removed during the scleral buckling procedure to achieve adequate buckle height in those eyes during surgery, and to avoid IOP elevation and closure of central retinal artery after fixation of the buckle and postoperatively. Thompson and Michels20 reported that a single 5-mm radial sponge of moderate height displaces 0.2 mL of fluid and a circumferential 2.5-mm-wide band of moderate height displaces 0.5 mL of fluid. Postoperative IOP elevation in Group A was reported in 2 eyes (16.7%) and was controlled by medications. This matches with the study of Acar et al17 who reported IOP elevation in 1 eye (14.3%) after conventional scleral buckling for complicated retinal detachment in silicone oil-filled eyes. Also, scleral buckling in silicone oil-filled eyes is not free of risks because hypotony that might exist in these eyes during placement of the buckle may increase the risk of choroidal hemorrhage.21 However, choroidal hemorrhage was not reported in any of the eyes of this study. In this study, scleral buckling consumed statistically significant less operation time than PPV (38.7 vs. 65.3 minutes) and achieved almost similar anatomical cure rate (83.3 vs. 81.8%) with the use of a less invasive surgical technique. The 83.3% anatomical success rate after scleral buckling in Group A after a mean follow-up period of 15 ± 3.22 months was higher than the 71.4% anatomical success rate achieved by Acar et al17 after one conventional retinal detachment surgery with a mean follow-up of 17.28 ± 8.64 months. The higher success rate in this study may be attributed to case selection because eyes with extensive PVR (PVR .C3) were excluded while in the study of Acar et al,17 4 eyes (57%) had starfolds
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and/or preretinal membranes. Mester et al22 by the use of scleral buckling reported a primary success rate of 82.9% in 41 vitrectomized eyes, which is comparable to the results achieved in this study. However, the anatomical success rate in Group B was 81.8% after PPV with a mean follow-up period of 14.18 ± 2.99 months. This is less than the 100% success rate achieved in a study of 6 eyes treated by PPV and reinjection of silicone oil,8 but 2 of them developed macular epiretinal membrane and in 1 eye of them, the retina was redetached when the silicone oil was removed during a subsequent macular surgery. In their retrospective study on 118 silicone oil-filled eyes with recurrent retinal detachment, Sharma et al2 reported a primary anatomical success rate of 45.8% increased to 62.7% with reoperation. Their cases were managed with revision of vitrectomy with membrane surgery with or without silicone oil removal, just scleral buckling, or both. The lower success rate in their study may be because PVR of various grades was present in 82.2% of their cases, and was extensive in most of these cases. Preoperative visual acuity was between hand movement and 20/80 in Group A, and was between hand movement and 20/125 in Group B. At the end of the follow-up duration, the mean logMAR BCVA has improved in both groups and the improvements were not significant. Also, there was no statistically significant difference between the mean BCVA of both groups; both before and after surgery. The BCVA improved by .two lines in five eyes in Group A and in four eyes in Group B, and remained unchanged in three eyes each in Group A and Group B. The BCVA did not deteriorate in any of the eyes of both groups. This relatively fair improvement of visual acuity in both groups of this study could be explained by selection of cases with PVR #C3. Also, the presence of silicone oil inside the globe decreases the height of retinal detachment and prevents its extension to the macula.2 By the end of the follow-up duration, none of the eyes of Group A and only 1 eye (9%) in Group B had a visual acuity less than ambulatory vision (.5/ 200). In their study on management of recurrent retinal detachment in silicone oil-filled eyes, Sharma et al2 reported that 59.5% of the successfully treated eyes had a final visual acuity $5/200 at the last follow-up. After silicone oil removal, the retina remained attached in 10 of the 12 eyes (83.3%) and was redetached in 2 eyes (16.7%) in Group A, while in Group B, the retina remained attached in 9 of the 11 eyes (81.8%) and was redetached in 2 eyes (18.2%). In the two recurrent cases of Group A, revitrectomy was done with the removal of any epiretinal membranes, perflourocarbon liquid injection, relaxing retinotomy,
1082 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES
and silicone oil reinjection. The retina was attached under silicone oil in the two recurrent cases till the last follow-up visit. In Group B, 1 of the 2 recurrent cases had extensive posterior PVR and underwent further vitreoretinal surgery, retinectomy, and heavy silicone oil (Densiron 68) injection, whereas the second patient reclined further surgery. Scholda et al23 reported recurrence of retinal detachment after silicone oil removal in 18 of the 112 eyes (16%) in their study. In a prospective study on 62 eyes with complicated retinal detachment, Flaxel et al24 reported 34% (21 eyes) recurrence of detachment after silicone oil removal. Another retrospective study25 on 287 consecutive eyes reported that retinal redetachment occurred in 20% of eyes after silicone oil removal, and the risk factors for recurrence were male sex, preoperative rubiosis, and proliferative diabetic retinopathy. No vision threatening complications occurred in eyes of both groups. Postoperative buckle infection and ocular motility disorders occurred only in eyes of Group A while cataract occurred significantly more in Group B eyes. In conclusion, inferior retinal detachment in silicone oil-filled eyes could be treated by a supplemental scleral buckling and external drainage of SRF with a high success rate comparable to the treatment with PPV and endotamponade, provided that PVR is not extensive. Scleral buckling could offer a faster, less invasive, and better economic alternative to repeated vitreoretinal surgery for treatment of such cases. Although few cases and the absence of true randomization could be limitations in this study, but it raises the necessity for a larger or multicenter study to put the guidelines of treatment of inferior retinal detachment in siliscone oilfilled eyes regarding the surgical options for different grades of PVR and their cost-effectiveness. Key words: scleral buckling, inferior retinal detachment, silicone oil-filled eyes. References 1. Morphis G, Irigoyen C, Eleuteri A, et al. Retrospective review of 50 eyes with long term silicone oil tamponade for more than 12 months. Graefes Arch Clin Exp Ophthalmol 2012;250:645–652. 2. Sharma T, Gopal L, Shanmugam MP, et al. Management of recurrent retinal detachment in silicone oil-filled eyes. Retina 2002;22:153–157. 3. Wolf S, Schon V, Meier P, Wiedemann P. Silicone oil-RMN3 mixture (“heavy silicone oil”) as internal tamponade for complicated retinal detachment. Retina 2003;23:335–342. 4. Boscia F, Furino C, Recchimurzo N, et al. Oxane HD vs silicone oil and scleral buckle in retinal detachment with proliferative vitreoretinopathy and inferior retinal breaks. Graefes Arch Clin Exp Ophthalmol 2008;246:943–948. 5. Wetterqvist C, Wong D, Williams R, et al. Tamponade efficiency of perfluorohexyloctane and silicone oil solutions in a model eye chamber. Br J Ophthalmol 2004;88:692–696.
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6. Singh AK, Michels RG, Glaser BM. Scleral indentation following cryotherapy and repeat cryotherapy enhance release of viable retinal pigment epithelial cells. Retina 1986;6:176–178. 7. Singh AK, Glaser BM, Lemor M, et al. Gravity-dependent distribution of retinal pigment epithelial cells dispersed into the vitreous cavity. Retina 1986;6:77–80. 8. Vilaplana Blanch D, Escoto Gonzalez R, Guinot Saera A. Treatment of retinal redetachment in eyes with intraocular silicone oil [in Spanish]. Arch Soc Esp Oftalmol 2001;76: 241–248. 9. Quiram PA, Gonzales CR, Hu W, et al. Outcomes of vitrectomy with inferior retinectomy in patients with recurrent rhegmatogenous retinal detachments and proliferative vitreoretinopathy. Ophthalmology 2006;113:2041–2047. 10. Sandner D, Engelmann K. First experience with high-density silicone oil (Densiron) as an intraocular tamponade in complex retinal detachment. Graefes Arch Clin Exp Ophthalmol 2006; 244:609–619. 11. Majid MA, Hussin HM, Biswas S, et al. Emulsification of Densiron-68 used in inferior retinal detachment surgery. Eye (Lond) 2008;22:152–157. 12. Ferris FL III, Kassoff A, Bresnick GH, Bailey I. New visual acuity charts for clinical research. Am J Ophthalmol 1982;94: 91–96. 13. Holladay JT. Proper method for calculating average visual acuity. J Refract Surg 1997;13:388–391. 14. Colyer MH, Barazi MK, Von Fricken MA. Retrospective comparison of 25-gauge transconjunctival sutureless vitrectomy to 20-gauge vitrectomy for the repair of pseudophakic primary inferior rhegmatogenous retinal detachment. Retina 2010;30: 1678–1684. 15. Quintyn JC, Ponchel C, Fillaux J, et al. Retinal detachment by inferior tear: a poor prognosis? [in French]. J Fr Ophtalmol 2005;28:953–957. 16. Gastaud P, Freton A. Inferior retinal detachment with silicone oil tamponade [in French]. J Fr Ophtalmol 2007;30:852–860. 17. Acar MA, Unlu N, Hazirolan D, et al. Conventional surgery for complicated retinal detachment in silicone oil-filled eyes. Eur J Ophthalmol 2011;21:290–295. 18. Rush R, Sheth S, Surka S, et al. Postoperative perfluoro-Noctane tamponade for primary retinal detachment repair. Retina 2012;32:1114–1120. 19. Alexander P, Ang A, Poulson A, Snead MP. Scleral buckling combined with vitrectomy for the management of rhegmatogenous retinal detachment associated with inferior retinal breaks. Eye (Lond) 2008;22:200–203. 20. Thompson JT, Michels RG. Volume displacement of scleral buckles. Arch Ophthalmol 1985;103:1822–1824. 21. Tabandeh H, Sullivan PM, Smahliuk P, et al. Suprachoroidal hemorrhage during pars plana vitrectomy. Risk factors and outcomes. Ophthalmology 1999;106:236–242. 22. Mester U, Anterist N, Kroll P, Brieden-Azvedo S. The role of the vitreous in retinal detachment surgery with external buckling. Ophthalmologica 2002;216:242–245. 23. Scholda C, Egger S, Lakits A, et al. Retinal detachment after silicone oil removal. Acta Ophthalmol Scand 2000; 78:182–186. 24. Flaxel CJ, Mitchell SM, Aylward GW. Visual outcome after silicone oil removal and recurrent retinal detachment repair. Eye (Lond) 2000;14:834–838. 25. Goennzine F, La Heig EC, Berendscot TT, et al. Risk factors for redetachment and worse visual outcome after silicone oil removal in eyes with complicated retinal detachment. Eur J Ophthalmol 2007;17:627–637.
S
silicone oil bubble which is lighter than water and floats with positive buoyancy. This makes the subretinal fluid (SRF) accumulate in the inferior quadrants.3,4 Also, the bubble of silicone oil is rounded and this decreases the tamponade efficiency because part of the volume is used to form the meniscus instead of making contact with the retina.5 Another reason is that PVR has a propensity to occur in the inferior retina in silicone oil-filled eyes.5 The standard
ilicone oil is an established endotamponade in the treatment of complex vitreoretinal disease.1 The rate of recurrence of retinal detachment in silicone oil-filled eyes varies in different studies from 21.4% to 77%. The main causes of recurrence are open peripheral inferior retinal breaks, proliferative vitreoretinopathy (PVR), and intrinsic retinal contraction.2 Recurrence mostly affects the lower retinal quadrants and this is mainly because of the displacement of 1076
SCLERAL BUCKLING IN SILICONE-FILLED EYES SOLAIMAN AND DABOUR
surgical approach for such cases is repeated vitrectomy with silicone oil removal, elimination of tractions that usually includes relaxing retinotomy and retinectomy, use of perflourocarbon liquids, reattachment of the retina, and silicone oil or gas tamponade at the end of surgery.6,7 Some surgeons reported the use of scleral buckling combined with vitreoretinal surgery for treatment of such cases.8,9 Heavy silicone oil has been lately used with promising success as a tamponade for recurrent inferior rhegmatogenous retinal detachment (RRD) and PVR,10 although there are some concerns about its emulsification that necessitated its removal in a significant percentage of cases.11 However, in their study on the management of recurrent retinal detachment in silicone oil-filled eyes, Sharma et al2 had reported the absence of guidelines of reoperation on silicone oil-filled eyes in terms of surgical options, types of proliferation that cause recurrence of retinal detachment, and the anatomical and functional outcomes with different surgical techniques. This study was planned to study the efficiency of treating selected cases of inferior retinal detachment in silicone oil-filled eyes using a supplemental scleral buckling with external drainage of SRF, versus the standard of performing a second vitreoretinal surgery and silicone oil endotamponade. Patients and Methods This prospective interventional pilot study included 23 consecutive silicone oil-filled eyes with inferior retinal detachment. The study protocol adheres to the tenets of the Declaration of Helsinki (1996) and the regulations of the Medical Review Board of Zagazig University Hospital. After obtaining informed consent, eyes were alternatively allocated into 2 groups: Group A included 12 eyes treated with supplemental scleral buckling with drainage of SRF and without the removal of silicone oil, and Group B included 11 eyes treated traditionally with silicone oil removal, revitrectomy, and reinjection of silicone oil. The study exclusion criteria included eyes with PVR .C3, too posterior retinal breaks (inside the main vascular arcades), giant retinal break, previous scleral buckling, subretinal silicone oil, and eyes with any complication related to silicone oil. The retina was initially attached completely in all eyes in Group A and in Group B for From the Faculty of Medicine, Department of Ophthalmology, Zagazig University, Zagazig, Sharkeya, Egypt. None of the authors have any financial/conflicting interests to disclose. Reprint requests: Kamal A. M. Solaiman, MD, Faculty of Medicine, Department of Ophthalmology, Zagazig University, Zagazig, Sharkeya, Egypt; e-mail: [email protected]
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at least 1 month after the first surgery. Patients were prepared for the second surgery once recurrent inferior detachment was diagnosed. All eyes were subjected to complete ophthalmic examination including logarithm of the minimum angle of resolution best-corrected visual acuity (logMAR BCVA), cycloplegic refraction, slit-lamp biomicroscopy, and indirect ophthalmoscopy. The preoperative data included age, sex, indications and details of primary vitreoretinal surgery, cause of retinal redetachment, SRF, grade of PVR, the duration between primary vitreoretinal surgery and reoperation, and lens status. All surgeries in both groups were performed by the two authors of this article. In Group A patients, a 360° periotomy and isolation of the 4 recti muscles were performed followed by localization of the open retinal breaks and external retinal cryopexy, then placement of scleral sutures, external drainage of any significant SRF, and placement of an explant. Round silicone sponges 4 mm or 5 mm in inferior quadrants or a segment of silicone tire 287 with a 240 encircling band were used. Tires were used in 3 eyes (Cases 2, 7, and 11) as segmental buckles to support anteriorly located breaks and PVR, and the encircling buckle was completed with a Band 240. In Cases 2 and 7, tire was used for only 3 hours while it was used for 6 hours in Case 11. In 7 eyes (58.3%), 0.2 mLto 0.6 mL silicone oil was removed through 20-gauge pars plana sclerotomy to adjust the height of the scleral buckle without intraocular pressure (IOP) elevation. In Group B patients, after doing the standard three-port pars plana sclerotomies, silicone oil was removed through the upper sclerotomy by active suction. Triamcinolone acetonide was injected to visualize and remove any residual vitreous strands. Peeling of any epiretinal membrane was performed and perflourocarbon liquid was injected for internal drainage of SRF. Fluid–air exchange was performed and then silicone oil was injected again. Endolaser photocoagulation was applied around the open breaks under perflourocarbon liquid or under air. The postoperative examinations included the BCVA, retina status, PVR, silicone oil, and any reported complication. Follow-up examinations were scheduled at Day 1, weekly for 1 month, and monthly thereafter till the end of the follow-up period which extended after silicone oil removal for at least 2 months or occurrence of retinal redetachment within these 2 months. The primary outcome measure was the anatomical success which is defined as complete reattachment of the retina and closure of any open retinal break(s) with no residual SRF for at least 2 months after silicone oil removal. The secondary outcome measures are the change in the BCVA and any reported complication related to the procedure itself.
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Table 1. Preoperative Clinical Characteristics of Patients in Both Groups Variable
Group A
Group B
P
Male:female Mean age ± SD, years BCVA, mean logMAR Mean no. breaks per eye Mean clock hours of RD per eye Mean time after the first procedure, months
8:4 34.08 ± 16.03 1.82 ± 0.72 1.58 ± 0.80 2.7 ± 0.96 2.83 ± 1.22
7:4 40.91 ± 19.79 1.93 ± 0.74 1.48 ± 0.66 2.4 ± 1.03 3.00 ± 1.61
.0.05 .0.05 .0.05 .0.05 .0.05 .0.05
SD, standard deviation.
(Table 1). The average number of detached clock hours per eye was 2.7 ± 0.96 in Group A and 2.4 ± 1.03 in Group B, caused by a mean of 1.58 ± 0.80 break per eye in Group A and 1.48 ± 0.66 break per eye in Group B, with no statistically significant difference between both groups (P . 0.05). Retinal breaks in all eyes of the study were ,2 clock hours. The mean follow-up duration was 15.00 ± 3.22 months in Group A and was 14.18 ± 2.99 months in Group B, with no significant difference between both groups (P . 0.05). At baseline, four eyes in each group were pseudophakic with intact posterior capsules, and only one eye in Group A was aphakic with torn posterior capsule. The indications for primary vitreoretinal surgery in eyes of Group A and Group B were mentioned in Tables 2 and 4, respectively. In Group A, the indications for primary vitreoretinal surgery were primary RRD associated with PVR (six eyes), intraocular foreign body (IOFB) with RRD (two eyes), rupture globe (one eye), and penetrating trauma (one eye). In addition, one eye had IOFB with endophthalmitis and the other eye had macular hole. In Group B, the indications for primary vitreoretinal surgery were primary RRD associated with PVR (five eyes), IOFB with RRD (one eye), IOFB with
Statistical analyses of data were done using SPSS version 15 (SPSS Inc, Chicago, IL). Quantitative data were reported as mean ± standard deviation. Paired t-test was used to compare logMAR BCVA of each group at baseline and at the end of follow-up duration. A Student’s t-test was used to determine statistical significance between both groups. A P # 0.05 was considered to be significant. Snellen visual acuity was converted into logMAR values as developed by Ferris et al.12 The logMAR value of hand movement visual acuity was assigned +3.0 logMAR and counting fingers visual acuity was assigned +2.0 logMAR according to methods published by Holladay.13
Results The study included 23 consecutive eyes (23 patients) with inferior retinal detachment in the presence of silicone oil tamponade. Eyes were alternatively distributed between Group A (12 eyes) and Group B (11 eyes). No statistically significant differences (P . 0.05) were detected between both groups in the preoperative demographic, functional, and anatomical characteristics
Table 2. Demographic and Preoperative Data of Patients in Group A
Number Sex
Age, years
1
F
35
2 3 4 5 6 7 8 9
M M F M M F M M
22 48 28 50 17 42 48 15
10
F
62
11 12
M M
12 30
Indication for Primary Vitreoretinal Surgery RRD, posterior break, PVR IOFB, endophthalmitis RRD, PVR IOFB, RRD RRD, PVR RRD, PVR RRD, multiple breaks Macular hole Penetrating trauma, RRD RRD, posterior break, PVR Rupture globe, RRD IOFB, RRD
Duration Between the First and Second Surgery, months
Preoperative Vision
PVR Grade
4
1.8
C1
Phakic
2 3 4 5 2.5 1.5 2 3
0.6 3.0 1.0 2.0 3.0 1.8 2.0 1.8
— C2 C3 C3 — — C1 C2
Phakic Pseudophakic Phakic Pseudophakic Phakic Phakic Phakic Aphakic
4
2.0
C2
Phakic
2 1
1.8 1.0
— C2
Pseudophakic Pseudophakic
Lens Status
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SCLERAL BUCKLING IN SILICONE-FILLED EYES SOLAIMAN AND DABOUR Table 3. Operative and Postoperative Data of Patients in Group A
Scleral Buckle
Retina After Scleral Buckling
5 mm sponge 4 mm sponge Tire 287 + Band 240 4 mm sponge 5 mm sponge 5 mm sponge Tire 287 + Band 240 5 mm sponge 5 mm sponge 4 mm sponge Tire 287 + Band 240 5 mm sponge
Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached
Number 1 2 3 4 5 6 7 8 9 10 11 12
Complications
Retina After Silicone Oil Removal
Vision After Silicone Oil Removal
Follow-up, months
[IOP, cataract — [IOP, buckle infection — — — Cataract, silicone in AC Cataract, [PVR — [PVR — —
Attached Attached Attached Attached Attached Attached Attached Detached Attached Detached Attached Attached
1.0 0.6 1.8 0.8 2.0 2.0 1.0 1.8 1.1 2.0 1.6 0.8
12 21 19 18 14 17 15 16 12 11 13 12
AC, anterior chamber; [, increase.
endophthalmitis (one eye), and penetrating trauma (one eye). In addition, two eyes had macular hole and one eye had a combined tractional RRD. Recurrence of retinal detachment in the inferior retinal quadrants was because of open inferior peripheral retinal break(s) in all eyes of both groups and mild anterior PVR (#C3) in 8 eyes (75%) in Group A and 8 eyes (72.7%) in Group B. The mean interval between the primary vitreoretinal surgery and the scleral buckling procedure in Group A patients was 2.83 ± 1.22 months (range, 1–5 months), while in Group B, the mean interval between the primary and the secondary vitreoretinal surgeries was 3.00 ± 1.61 months (range, 1–6 months). Details of the scleral buckling procedures in Group A patients are shown in Table 3. Operative and postoperative details of Group B patients are shown in Table 5. The mean operative time in Group A was 38.7 ± 11.2 minutes that was statistically significantly lower than the mean operative time (65.3 ± 15.1 minutes) in Group B (P , 0.05). After silicone
oil removal, the retina was attached in 10 of the 12 eyes (83.3%) and redetached in 2 eyes (16.7%) in Group A. After silicone oil removal in Group B, the retina was attached in 9 of the 11 eyes (81.8%) and redetached in 2 eyes (18.2%). The mean logMAR BCVA has improved from 1.82 ± 0.72 to 1.36 ± 0.52 in Group A patients (P . 0.05) and from 1.93 ± 0.74 to 1.55 ± 0.63 in Group B patients (P . 0.05) at the end of the follow-up duration. Also, there was no statistically significant difference between the mean BCVA of both groups; both before and after surgery (P . 0.05). The BCVA improved by greater than two lines in five eyes in Group A and in four eyes in Group B, and remained unchanged in three eyes each in Group A and Group B. The BCVA did not deteriorate in any of the eyes of both groups. Iatrogenic retinal break occurred in 2 eyes (18%) in Group B and was treated intraoperatively by endolaser retinopexy. Cataract occurred in 3 eyes (25%) in
Table 4. Demographic and Preoperative Data of Patients in Group B
Number Sex
Age, years
1 2 3
M M F
24 26 55
4 5 6 7 8 9 10 11
F F F M F M M M
60 58 62 30 70 26 18 21
Indication for Primary Vitreoretinal Surgery Old RD, large break RRD, multiple breaks, PVR Combined tractional rhegmatogenous RD Macular hole Posterior break, PVR Myopic macular hole IOFB, endophthalmitis RRD, posterior break, PVR IOFB, RRD Penetrating trauma, RRD RRD, posterior break, PVR
Duration Between the First and Second Surgery, months
Preoperative Vision
PVR Grade
Lens Status
4 2 3
3.0 1.8 1.8
C2 C2 C3
Phakic Pseudophakic Phakic
4 5 2.5 1.5 2 3 4 1
1.5 1.0 1.5 1.3 3.0 2.0 3.0 1.3
— C1 C2 — C2 — C3 C1
Pseudophakic Phakic Phakic Phakic Phakic Pseudophakic Pseudophakic Phakic
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Table 5. Operative and Postoperative Data of Patients in Group B Number 1 2 3 4 5 6 7 8 9 10 11
Retina After PPV
Complications
Retina After Silicone Oil Removal
Vision After Silicone Oil Removal
Follow-up, months
Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached Attached
Cataract — [IOP, cataract — — [IOP Cataract Cataract Retinal break [PVR, cataract Cataract
Attached Attached Attached Attached Attached Attached Attached Detached Attached Detached Attached
2.0 1.0 1.1 1.3 1.0 1.3 1.1 2.0 2.0 3.0 1.2
17 20 12 18 15 12 13 14 12 13 11
[, increase.
Group A and in 6 eyes (54.55%) in Group B (P , 0.05), and was removed by phacoemulsification and intraocular lens implantation either in a separate session or during silicone oil removal, without complications related to cataract surgery in all cases. Elevation of IOP in the early postoperative period occurred in 2 eyes (16.7%) in Group A and in 2 eyes (18.2%) in Group B, and was controlled by medications. Postoperative hypotony occurred in 1 eye (8.3%) in Group A and in 2 eyes (18%) in Group B. Buckle infection occurred in 1 eye (8.3%) and was controlled by medications. Ocular motility disturbances were observed in 2 eyes (16.7%) in group A, and in no eye in group B. Postoperative intraocular inflammation did not exceed the usual amount of postvitrectomy/scleral buckling inflammation in all eyes. Silicone oil in anterior chamber was detected in 1 eye (8.3%) in Group A. Epiretinal membrane formation was found in 3 eyes (25%) in Group A and in 2 eyes (18%) in Group B, and was surgically removed during silicone oil removal. Subretinal silicone oil migration was not observed in any of the eyes of both groups. Proliferative vitreoretinopathy has increased postoperatively in 2 eyes (16.7%) in Group A and in 1 eye (9%) in Group B. Retinal redetachment after silicone oil removal occurred in 2 eyes (16.7%) in Group A and in 2 eyes (18.2%) in Group B. Hypotony occurred after the removal of silicone oil in 2 eyes (16.7%) in Group A and in 2 eyes (18%) in Group B.
Discussion Since Custodis introduced scleral buckling as an effective treatment modality, it remains the “gold standard” in the treatment of RRDs. However, after Machemer’s introduction of vitrectomy as a useful technique in the management of complex vitreoreti-
nal diseases, the visual outcomes have been improved to approach, and in some cases exceed, those of the gold standard of scleral buckling.14 Also, the advent of silicone oil as an endotamponade in the treatment of complicated retinal detachment has led to more improvement in the success rate. The prognosis of inferior retinal detachment is usually guarded in both primary and recurrent cases.2,15 Recurrence of inferior retinal detachment after a vitreoretinal surgery and silicone oil tamponade is usually attributed to PVR2 and/or inadequate or unidirectional (superiorly directed) retinal tamponade with silicone oil, especially when a strict continuous posturing is not adhered to in the first few postoperative days.10 In the last few years, numerous investigators have published the outcomes of vitreoretinal surgery to treat recurrent inferior retinal detachment with fair anatomical and functional outcomes.2,8,9 However, the studies that investigated the use of scleral buckling for the treatment of recurrent inferior retinal detachment in silicone oil-filled eyes were very limited.16,17 Scleral buckling for inferior retinal detachment in silicone oil-filled eyes has many advantages. It increases the tamponading effect of silicone oil on the inferior retina, relieves the traction on the retina circumferentially and supports the retinal breaks.5 Also, by bringing the inferior retina closer to the silicone oil bubble, the scleral buckling will theoretically float the proliferative cells and the mediators of cellular proliferation away from the detached inferior retina in the upright position, and thus decreases PVR and consequently the rate of inferior retinal redetachment.18 Also, if recurrence occurs after scleral buckling, the support of the traction forces on the vitreous base and the retinal breaks is expected to add to the success of the subsequent vitreoretinal surgery.4,19 Based on the above mentioned data, we investigated
SCLERAL BUCKLING IN SILICONE-FILLED EYES SOLAIMAN AND DABOUR
the use of scleral buckling as a treatment modality for treatment of selected cases of inferior retinal detachment in silicone oil-filled eyes, and compared this group with another matching group of patients treated with the standard surgical approach in such cases; repeated vitreoretinal surgery and silicone oil endotamponade. Reoperation was a must in those eyes because detachment was recurrent and there were open retinal breaks continuous with the inferior retinal detachment, and a certain degree of PVR. If those eyes were left without treatment, they would be at risk of retinal detachment progression and that risk could greatly increase after the removal of silicone oil. Surgery on silicone oil-filled eyes calls for an additional surgical skill and meticulous planning.2 A precise adjustment of the height of the scleral buckle is essential to achieve adequate support of retinal breaks and to keep adequate internal tamponade effect by silicone oil without IOP elevation. In 7 eyes (58.3%) of Group A, 0.2 mL to 0.6 mL of silicone oil was removed during the scleral buckling procedure to achieve adequate buckle height in those eyes during surgery, and to avoid IOP elevation and closure of central retinal artery after fixation of the buckle and postoperatively. Thompson and Michels20 reported that a single 5-mm radial sponge of moderate height displaces 0.2 mL of fluid and a circumferential 2.5-mm-wide band of moderate height displaces 0.5 mL of fluid. Postoperative IOP elevation in Group A was reported in 2 eyes (16.7%) and was controlled by medications. This matches with the study of Acar et al17 who reported IOP elevation in 1 eye (14.3%) after conventional scleral buckling for complicated retinal detachment in silicone oil-filled eyes. Also, scleral buckling in silicone oil-filled eyes is not free of risks because hypotony that might exist in these eyes during placement of the buckle may increase the risk of choroidal hemorrhage.21 However, choroidal hemorrhage was not reported in any of the eyes of this study. In this study, scleral buckling consumed statistically significant less operation time than PPV (38.7 vs. 65.3 minutes) and achieved almost similar anatomical cure rate (83.3 vs. 81.8%) with the use of a less invasive surgical technique. The 83.3% anatomical success rate after scleral buckling in Group A after a mean follow-up period of 15 ± 3.22 months was higher than the 71.4% anatomical success rate achieved by Acar et al17 after one conventional retinal detachment surgery with a mean follow-up of 17.28 ± 8.64 months. The higher success rate in this study may be attributed to case selection because eyes with extensive PVR (PVR .C3) were excluded while in the study of Acar et al,17 4 eyes (57%) had starfolds
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and/or preretinal membranes. Mester et al22 by the use of scleral buckling reported a primary success rate of 82.9% in 41 vitrectomized eyes, which is comparable to the results achieved in this study. However, the anatomical success rate in Group B was 81.8% after PPV with a mean follow-up period of 14.18 ± 2.99 months. This is less than the 100% success rate achieved in a study of 6 eyes treated by PPV and reinjection of silicone oil,8 but 2 of them developed macular epiretinal membrane and in 1 eye of them, the retina was redetached when the silicone oil was removed during a subsequent macular surgery. In their retrospective study on 118 silicone oil-filled eyes with recurrent retinal detachment, Sharma et al2 reported a primary anatomical success rate of 45.8% increased to 62.7% with reoperation. Their cases were managed with revision of vitrectomy with membrane surgery with or without silicone oil removal, just scleral buckling, or both. The lower success rate in their study may be because PVR of various grades was present in 82.2% of their cases, and was extensive in most of these cases. Preoperative visual acuity was between hand movement and 20/80 in Group A, and was between hand movement and 20/125 in Group B. At the end of the follow-up duration, the mean logMAR BCVA has improved in both groups and the improvements were not significant. Also, there was no statistically significant difference between the mean BCVA of both groups; both before and after surgery. The BCVA improved by .two lines in five eyes in Group A and in four eyes in Group B, and remained unchanged in three eyes each in Group A and Group B. The BCVA did not deteriorate in any of the eyes of both groups. This relatively fair improvement of visual acuity in both groups of this study could be explained by selection of cases with PVR #C3. Also, the presence of silicone oil inside the globe decreases the height of retinal detachment and prevents its extension to the macula.2 By the end of the follow-up duration, none of the eyes of Group A and only 1 eye (9%) in Group B had a visual acuity less than ambulatory vision (.5/ 200). In their study on management of recurrent retinal detachment in silicone oil-filled eyes, Sharma et al2 reported that 59.5% of the successfully treated eyes had a final visual acuity $5/200 at the last follow-up. After silicone oil removal, the retina remained attached in 10 of the 12 eyes (83.3%) and was redetached in 2 eyes (16.7%) in Group A, while in Group B, the retina remained attached in 9 of the 11 eyes (81.8%) and was redetached in 2 eyes (18.2%). In the two recurrent cases of Group A, revitrectomy was done with the removal of any epiretinal membranes, perflourocarbon liquid injection, relaxing retinotomy,
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and silicone oil reinjection. The retina was attached under silicone oil in the two recurrent cases till the last follow-up visit. In Group B, 1 of the 2 recurrent cases had extensive posterior PVR and underwent further vitreoretinal surgery, retinectomy, and heavy silicone oil (Densiron 68) injection, whereas the second patient reclined further surgery. Scholda et al23 reported recurrence of retinal detachment after silicone oil removal in 18 of the 112 eyes (16%) in their study. In a prospective study on 62 eyes with complicated retinal detachment, Flaxel et al24 reported 34% (21 eyes) recurrence of detachment after silicone oil removal. Another retrospective study25 on 287 consecutive eyes reported that retinal redetachment occurred in 20% of eyes after silicone oil removal, and the risk factors for recurrence were male sex, preoperative rubiosis, and proliferative diabetic retinopathy. No vision threatening complications occurred in eyes of both groups. Postoperative buckle infection and ocular motility disorders occurred only in eyes of Group A while cataract occurred significantly more in Group B eyes. In conclusion, inferior retinal detachment in silicone oil-filled eyes could be treated by a supplemental scleral buckling and external drainage of SRF with a high success rate comparable to the treatment with PPV and endotamponade, provided that PVR is not extensive. Scleral buckling could offer a faster, less invasive, and better economic alternative to repeated vitreoretinal surgery for treatment of such cases. Although few cases and the absence of true randomization could be limitations in this study, but it raises the necessity for a larger or multicenter study to put the guidelines of treatment of inferior retinal detachment in siliscone oilfilled eyes regarding the surgical options for different grades of PVR and their cost-effectiveness. Key words: scleral buckling, inferior retinal detachment, silicone oil-filled eyes. References 1. Morphis G, Irigoyen C, Eleuteri A, et al. Retrospective review of 50 eyes with long term silicone oil tamponade for more than 12 months. Graefes Arch Clin Exp Ophthalmol 2012;250:645–652. 2. Sharma T, Gopal L, Shanmugam MP, et al. Management of recurrent retinal detachment in silicone oil-filled eyes. Retina 2002;22:153–157. 3. Wolf S, Schon V, Meier P, Wiedemann P. Silicone oil-RMN3 mixture (“heavy silicone oil”) as internal tamponade for complicated retinal detachment. Retina 2003;23:335–342. 4. Boscia F, Furino C, Recchimurzo N, et al. Oxane HD vs silicone oil and scleral buckle in retinal detachment with proliferative vitreoretinopathy and inferior retinal breaks. Graefes Arch Clin Exp Ophthalmol 2008;246:943–948. 5. Wetterqvist C, Wong D, Williams R, et al. Tamponade efficiency of perfluorohexyloctane and silicone oil solutions in a model eye chamber. Br J Ophthalmol 2004;88:692–696.
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6. Singh AK, Michels RG, Glaser BM. Scleral indentation following cryotherapy and repeat cryotherapy enhance release of viable retinal pigment epithelial cells. Retina 1986;6:176–178. 7. Singh AK, Glaser BM, Lemor M, et al. Gravity-dependent distribution of retinal pigment epithelial cells dispersed into the vitreous cavity. Retina 1986;6:77–80. 8. Vilaplana Blanch D, Escoto Gonzalez R, Guinot Saera A. Treatment of retinal redetachment in eyes with intraocular silicone oil [in Spanish]. Arch Soc Esp Oftalmol 2001;76: 241–248. 9. Quiram PA, Gonzales CR, Hu W, et al. Outcomes of vitrectomy with inferior retinectomy in patients with recurrent rhegmatogenous retinal detachments and proliferative vitreoretinopathy. Ophthalmology 2006;113:2041–2047. 10. Sandner D, Engelmann K. First experience with high-density silicone oil (Densiron) as an intraocular tamponade in complex retinal detachment. Graefes Arch Clin Exp Ophthalmol 2006; 244:609–619. 11. Majid MA, Hussin HM, Biswas S, et al. Emulsification of Densiron-68 used in inferior retinal detachment surgery. Eye (Lond) 2008;22:152–157. 12. Ferris FL III, Kassoff A, Bresnick GH, Bailey I. New visual acuity charts for clinical research. Am J Ophthalmol 1982;94: 91–96. 13. Holladay JT. Proper method for calculating average visual acuity. J Refract Surg 1997;13:388–391. 14. Colyer MH, Barazi MK, Von Fricken MA. Retrospective comparison of 25-gauge transconjunctival sutureless vitrectomy to 20-gauge vitrectomy for the repair of pseudophakic primary inferior rhegmatogenous retinal detachment. Retina 2010;30: 1678–1684. 15. Quintyn JC, Ponchel C, Fillaux J, et al. Retinal detachment by inferior tear: a poor prognosis? [in French]. J Fr Ophtalmol 2005;28:953–957. 16. Gastaud P, Freton A. Inferior retinal detachment with silicone oil tamponade [in French]. J Fr Ophtalmol 2007;30:852–860. 17. Acar MA, Unlu N, Hazirolan D, et al. Conventional surgery for complicated retinal detachment in silicone oil-filled eyes. Eur J Ophthalmol 2011;21:290–295. 18. Rush R, Sheth S, Surka S, et al. Postoperative perfluoro-Noctane tamponade for primary retinal detachment repair. Retina 2012;32:1114–1120. 19. Alexander P, Ang A, Poulson A, Snead MP. Scleral buckling combined with vitrectomy for the management of rhegmatogenous retinal detachment associated with inferior retinal breaks. Eye (Lond) 2008;22:200–203. 20. Thompson JT, Michels RG. Volume displacement of scleral buckles. Arch Ophthalmol 1985;103:1822–1824. 21. Tabandeh H, Sullivan PM, Smahliuk P, et al. Suprachoroidal hemorrhage during pars plana vitrectomy. Risk factors and outcomes. Ophthalmology 1999;106:236–242. 22. Mester U, Anterist N, Kroll P, Brieden-Azvedo S. The role of the vitreous in retinal detachment surgery with external buckling. Ophthalmologica 2002;216:242–245. 23. Scholda C, Egger S, Lakits A, et al. Retinal detachment after silicone oil removal. Acta Ophthalmol Scand 2000; 78:182–186. 24. Flaxel CJ, Mitchell SM, Aylward GW. Visual outcome after silicone oil removal and recurrent retinal detachment repair. Eye (Lond) 2000;14:834–838. 25. Goennzine F, La Heig EC, Berendscot TT, et al. Risk factors for redetachment and worse visual outcome after silicone oil removal in eyes with complicated retinal detachment. Eur J Ophthalmol 2007;17:627–637.
