In fact, some of these patients have abnormally adherent vitreoretinal interfaces. These types of patients don’t have a vitreous detachment or vitreous-separation-related detachment. Pockets of syneretic, liquid vitreous leak through these retinal holes and defects, which causes the retina to separate. Some patients, however, develop retinal detachment because they have congenital defects in the retina they are often very myopic, with their retinas stretched out. The cause of most retinal detachments is acute posterior vitreous detachment with retinal tear or tears, so the correct response is to remove the vitreous and any associated traction on the retina, and to treat the tear or tears. They added, however, that there was no difference in BCVA in pseudophakes and, based on a better anatomical outcome, recommended vitrectomy in these patients. The study surgeons wrote that buckling shows a benefit in phakic eyes with respect to BCVA improvement. The redetachment rate was 39.8 percent for scleral buckling (53/133) and 20 percent for vitrectomy (27/132) in the pseudophakic trial. In the phakic trial, the redetachment rate in the SB group was 26.3 percent (55/209 patients) and in the vitrectomy group it was 25.1 percent (52/207 patients). In pseudophakes, the mean number of retina-affecting secondary surgeries was lower in the vitrectomy group (SB: 0.77 ☑.08 PPV: 0.43 ☐.85 p=0.0032). In the pseudophakic group, the primary anatomical success rate (defined as retinal reattachment without any secondary retina-affecting surgery) was significantly better in the vitrectomy group (SB: 71/133 PPV: 95/132 ) ( p=0.0020). In phakic patients, cataract progression was greater in the PPV group ( p<0.00005). In the pseudophakic trial, changes in BCVA showed a nonsignificant difference of 0.09 logMAR. In the phakic trial, the mean BCVA change was significantly greater in the buckling group ( p=0.0005) (SB: -0.71 ☐.68 logMAR PPV: -0.56 ☐.76 logMAR ). Secondary endpoints were primary and final anatomical success, occurrence of proliferative vitreoretinopathy, cataract progression and the number of reoperations. There was one-year follow up in the study, and the primary outcome (change in best-corrected visual acuity) was assessed at one year. In a prospective, randomized, multicenter clinical trial, the Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment Study, 45 surgeons at 25 centers in Europe recruited 416 phakic and 265 pseudophakic retinal detachment patients over a five-year period. Researchers have compared these surgical approaches as well. This is the opposite of the ratio at which they were performed when I finished my fellowship. During this same time period, I performed 43 scleral buckling operations, a ratio of 2/3 in favor of vitrectomy. Vitrectomy is also very effective: I recently reviewed my last 100 cases of acute retinal detachment repaired by vitrectomy, and 94 of them were successfully repaired with one operation. Another reason for vitrectomy’s popularity is the fact that retinal specialists perform the procedure for many other reasons, such as macular pucker, macular hole and diabetic retinopathy, so the comfort level of young retinal surgeons is much higher than it is with scleral buckling. Buckling patients also occasionally suffer complications such as diplopia due to the buckle being placed beneath the ocular muscles infection globe ischemia and choroidal hemorrhage. Also, vitrectomy doesn’t alter the shape of the eye the way scleral buckling does. Unlike scleral buckling, vitrectomy has evolved, and doesn’t involve the kind of “blind” maneuvers scleral buckling requires, such as the external drainage of subretinal fluid. Advances in the equipment for vitrectomy are comparable to those advances for cataract surgery the removal of vitreous and traction on the retina is much less dangerous than it was 30 years ago. Why did this change occur? I believe it’s because vitrectomy is a safer, more controlled procedure. Now, however, most detachments are repaired with vitrectomies, even in situations in which a vitrectomy might not be the best option. Here, I’ll describe why vitrectomy has become popular, discuss some finer points of the technique and outline situations where scleral buckling may be preferable.Īs I mentioned earlier, in my initial training we tried to repair every retinal detachment with a scleral buckle first, with vitrectomy being a kind of last resort. Don’t discard scleral buckling completely, though, since it may still have a place in our treatment armamentarium. The change was made because of factors such as ease of technique and the potential safety benefits of vitrectomy. O ur approach to repairing rhegmatogenous retinal detachments has undergone a sea change over the years, moving from the scleral buckling we were taught to use in most cases in the last century to vitrectomy today.
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