Non-drainage scleral buckling with solid silicone elements

Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014 55

Background: With the increasing number of cataract surgeries, incidence of posterior segment complications including rhegmatogenous retinal detachment (RRD) is likely to rise. Scleral buckling (SB) surgery is an effective and less expensive option. The primary advantage of non-drainage procedure is avoidance of possible complications associated with trans-choroidal drainage. The aim of present study is to describe the clinical profile of subjects undergoing non-drainage SB surgery with solid silicone elements for RRD and analyze their treatment outcomes.

Materials and Methods: This was a retrospective, non-randomized, interventional study at a tertiary care center. Three hundred and six eyes of 298 patients undergoing non-drainage SB surgery with solid silicone elements from year 2000 to 2006 were included. Inclusion criteria were primary RRD, peripheral depressible retinal break, media clarity affording peripheral retinal view and proliferative vitreo-retinopathy (PVR) up to grade C2. Uni- and

multivariate analyses was done to analyze factors affecting anatomical and visual outcomes. Statistical analysis was performed using SPSS Version 10.

Results: Mean follow-up was 303 ± 393.33 days. Primary anatomical success was obtained in 279 (91.2%) eyes; primary functional success in 286 (93.5%) eyes. PVR (grade B or C), intraocular pressure <10 mm Hg and the inability to find a retinal break were significantly associated with final anatomical failure. Baseline vision ≤3/60 was significantly associated with poor visual recovery.

Conclusions: SB surgery is reasonably safe and highly efficacious. Solid silicone elements are effective in non-drainage SB surgery. However, case selection is important.

Keywords: Proliferative vitreoretinopathy, retinal detachment, scleral buckling, solid silicone, subretinal fluid

Introduction

Retinal detachment (RD) is an important, potentially blinding ocular condition, if not promptly treated. Scleral buckling (SB) is a widely used corrective procedure for RD. Two controversial aspects related to RD procedure are significant. First is the need (or no need) for sub-retinal fluid drainage.[1-6] Second is the

nature of buckling biomaterial for implantation. Largely, silicone elements are preferred because of their biocompatibility and chemical inertness.[7,8] There seems to be an advantage using solid silicone elements since a greater possibility for astigmatism,[9] post-operative infection and extrusion are reported with silicone sponges (2.7-18.0%)[10] than solid elements (0.2-1.4%).[11] The objective of this study was to describe the clinical profile of consecutive patients undergoing non-drainage SB surgery with solid silicone elements and outcomes of surgery.

Material and Methods

This was a retrospective study. One thousand eight hundred and sixty two eyes underwent SB surgery for primary rhegmatogenous retinal detachment (RRD) between 1 January 2000 and 31 December 2006, of which 306 (298 patients) eyes underwent a

Non-drainage scleral buckling with solid silicone elements

Pukhraj Rishi, Ekta Rishi, Aditi Gupta, Cheriyan Shane Mathew, Bhavesh J. Shah

Shri Bhagwan Mahavir Department of Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai, Tamil Nadu, India

Original Article

Correspondence:Dr. Pukhraj Rishi, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai - 600 006, Tamil Nadu, India.

E-mail: [email protected]

Copyright: © 2014 Rishi P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Website: www.ojoonline.org

DOI: 10.4103/0974-620X.137138

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Rishi, et al.: Non-drainage scleral buckling

56 Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014

‘non-drainage’ procedure. Inclusion criteria were the presence of primary RRD with peripheral depressible retinal break with media clarity enough to allow appropriate visualization of the entire retinal periphery. Eyes with proliferative vitreo-retinopathy (PVR) up to grade C2 satisfying the above criteria were included. Exclusion criteria included eyes with RD that required SB but had too shallow SRF to consider drainage, patients with follow-up of less than six weeks and RRD following proliferative diabetic retinopathy (PDR) and retinopathy of prematurity (ROP). RRD was considered as ‘shallow’ when the level of SRF was too low to consider drainage, so as to risk retinal incarceration.

Solid silicone buckling elements were used in all cases. Patients were examined next day and discharged. Patients were re-examined in the next few days depending upon the clinical condition. First major follow-up was at 6 weeks. Primary anatomical success was defined as reattachment of retina at six weeks follow-up. Primary functional success was defined as visual acuity maintained (BCVA improved or worsened by <2 lines of Snellen chart) or increased (BCVA improved >2 lines of Snellen chart) at six weeks follow-up. Final anatomical success was defined as reattachment of the retina at final follow-up. Early absorption of SRF was defined by absorption in less than 6 months, and late absorption as that seen after 6 months.

Statistical program SPSS Version 10 was used for data analysis. Snellen BCVA was converted to decimal acuity for the sake of analysis. P < 0.05 was taken to be significant. According to institutional policy, prior ethical approval was not required as this was a retrospective study.

Results

The study included 306 eyes of 298 patients. Mean age at presentation was 36.17 ± 18.29 years (range 7-77 years). Of 298 patients, 237 (79.5%) were males and 35 (11.7%) were children <16 years of age. Duration of RRD was <1 week in 46 (15.0%) eyes and >1 month in 97 (31.7%). Mean follow-up was 303 ± 393.33 days (median 91, range 21 to 2005 days). Table 1 depicts baseline preoperative data of study eyes. Of 70.9% eyes in which refractive history was available, 49.3% were myopic. Retinal cyst was present in nine (2.9%) eyes and demarcation line in 22 (7.2%). RRD was complicated by presence of vitreous haze in 70 (22.9%) eyes, cataract in 57 (18.6%) and subluxated lens in two (0.6%). IOP was >21 mm Hg pre-operatively in eight (2.6%) eyes, of which two had post-operative glaucoma requiring anti-glaucoma medications (AGM). In others, IOP was restored to within normal range postoperatively. Extent of detachment was ≤2 quadrants in 146 (47.7%) eyes (which included 16 eyes with <1/2 quadrant RD, 46 eye with ½ to 1 quadrant RD, 20 eyes with 1 to 1 and a half quadrant RD and >2 quadrants in 160 (52.3%) eyes. Macula was attached in 95 (31.1%) eyes, detached in 190 (62.1%) eyes and bisected in 20 (6.5%) eyes.

Table 2 provides operative details. An encircling 2.5-mm silicone band was placed in all but seven eyes. Intraoperative complications

included globe perforation in four (1.3%) eyes, raised IOP (even after paracentesis) in two (0.7%), retinal folds in eight (2.6%), persistent fish-mouthing of retinal break in one (0.3%), posterior cryo-freeze in one (0.3%) and injury to vortex vein in one (0.3%) eye. Postoperative complications included serous CD in 30 (9.8%) eyes, epiretinal membrane in five (1.6%), progression of cataract in six (2.0%) and raised IOP in eight (2.6%) eyes, of which one had angle-recession glaucoma, one developed pseudophakic glaucoma (bilateral) and two were known cases of glaucoma already on AGM. Three eyes developed exposure of buckle

Table 1: Clinical characteristics of 306 eyes treated

with non-drainage scleral buckling surgery

Variable Number of eyes (N) Percentage

Refractive error (D)

Myopia 151 49.3

Hyperopia 25 8.2

Emmetropia 41 13.4

Data not available 89 29.1

Lens status

Phakic 230 75.2

Pseudophakic 61 19.9

Aphakic 15 4.9

History of trauma

Present 68 22.2

IOP* (mm Hg)

<10 68 22.2

10 to 21 213 69.6

>21 8 2.6

Data not available 17 5.6

Extent of retinal detachment

≤2 quadrants 146 47.7

<½ quadrant 16

½ to 1 quadrant 46

1 to 1½ quadrant 20

1½ to 2 quadrant 64

>2 quadrants 160 52.3

2 to 2½ 20

2½ to 3 42

3 to 3½ 26

3½ to 4 72

Vitreous hemorrhage

Present 30 9.8

Macular status

Attached 95 31.1

Detached 190 62.1

Bisected 20 6.5

SRF*

Shallow 155 50.7

Bullous 139 45.4

Data not available 12 3.9

PVR†

Absent 267 87.2

Grade A 22 7.2

Grade B 6 2.0

Grade C1-2 11 3.6

Others

Subretinal gliosis 46 15

Choroidal detachment 4 1.3

Subretinal precipitates 25 8.2

*SRF: Sub-retinal fl uid, †PVR: Proliferative vitreo-retinopathy

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Rishi, et al.: Non-drainage scleral buckling

Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014 57

suture; suture was removed in two and buckle was removed in one, with stable fundus in follow-up period. Diplopia was present in three (1%) eyes that were corrected with appropriate prisms.

Table 3 shows absorption characteristics of SRF and postoperative RD in relation to time after surgery. Primary anatomical success was achieved in 279 (91.2%) eyes and final anatomical success in 270 (88.2%). Of 36 eyes with detached retina, at final follow-up visit, 22 eyes (61.1%) suffered RD between the first and sixth week of the postoperative period. Uni- and multivariate analysis revealed no significant association between delayed SRF absorption and factors like myopia >6 D, subretinal precipitates, bullous RD, RD duration >1 month and patient age >60 years.

Table 4 depicts causes of failure of surgery. Thirty (11.8%) eyes suffered anatomical failures, major cause being PVR (44.4%). Other causes included intrinsic retinal contracture with subretinal gliosis preventing reattachment, lifting of previously attached macular hole and misdiagnosis of exudative RD secondary to central serous retinopathy (CSR) in one eye, each. Causative agent for re-detachment was not clinically made out in four eyes (11.1%).

Table 5 shows factors associated with final anatomical failure. On both uni- and multivariate analysis, PVR (grade B or C), IOP < 10 mm Hg and the inability to find retinal break were significantly associated with final anatomical failure. Preoperative VA ≤3/60, age >60 years and presence of pseudophakia/aphakia were significant factors for final anatomical failure on univariate but not on multivariate analysis.

Figure 1 shows visual outcomes in relation to time of absorption of SRF. The percentage of eyes having improved vision was 75.2, 74.6, 74.6 and 73.7 in cases where SRF was absorbed within one day, one week, six weeks and at final follow-up, respectively. There was no statistically significant difference between the study groups.

Figure 2 represents overall visual outcome in terms of comparison between pre- and postoperative visual acuities (at six weeks of follow-up). Primary functional success was seen in 286 (93.5%) eyes. Overall, there was significant improvement

Table 2: Details of external (scleral buckle) and

internal tamponade in 306 eyes treated with

non-drainage scleral buckling surgery

Variable Number of eyes (N) Percentage

Buckle size

#42 2 0.6

#276 80 26.1

#277 5 1.6

#278 2 0.6

#279 156 51

#280 36 11.8

#281 8 2.6

Multiple buckles 17 5.6

Type of buckle

Exoplant 288 94.1

Implant 18 5.9

Orientation of buckle

Circumferential 304 99.3

Combination of radial

and circumferential

2 0.6

Intravitreal injection

Nil 239 78.1

Air 43 14.1

C3F

8gas 14 4.6

Saline 4 1.3

SF6 gas 5 1.6

Saline+air 1 0.3

Table 3: Characteristics of subretinal fluid

absorption and retinal re-attachment in relation to

recovery time after treatment with non-drainage

scleral buckling surgery

Recovery time

after surgery

Complete

SRF

absorption

Residual

SRF*

Detached

retina

N % N % N %

<24 h 153 50.0 150 49.0 3 1.0

1 week 232 75.8 69 22.6 5 1.6

6 weeks 264 86.3 15 4.9 27 8.8

Final follow-up 270 88.2 0 0 36 11.8

6 months (n†=128) 113 88.3 1 0.8 14 10.9

*SRF: Sub-retinal fl uid, †n: Number of subjects where 6 months follow-up

data was available

Table 4: Causes of postoperative retinal

detachment in 36 of 306 eyes after treatment

with non-drainage scleral buckling surgery

Causes Primary

failure

(n=27)

Early

detachment

(n=7)

Late

detachment

(n=2)

de novo PVR* 9 5 0

Progression of preoperative PVR 1 0 0

Break at the edge of PVR 1 0 0

Other causes 3 0 0

No causes found/no break seen 2 2 0

Missed/new breaks 7 0 2

Inadequate buckle 3 0 0

Inadequate retinopexy 1 0 0

*PVR: Proliferative vitreo-retinopathyFigure 1: Visual outcomes in relation to time of absorption of subretinal fl uid

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58 Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014

(P < 0.05) between preoperative (mean 1.16 ± 0.94) and postoperative (mean 0.71 ± 0.68) visual functions in reattached cases. Visual outcomes in successfully reattached ‘macula-off’ and ‘macula-on’ RDs were compared, separately. Of 182 eyes with successfully reattached macula-off RDs, 77 (42.3%) eyes had BCVA of 6/60 or better preoperatively while 148 eyes (81.3%) had BCVA of 6/60 or better at last follow-up. BCVA improved in 163 eyes (89.6%), was maintained in 15 eyes (8.2%) and deteriorated in four eyes (2.2%). In 88 eyes, in which macula-on RDs were successfully reattached, BCVA was maintained in 46 (52.3%), improved in 36 (40.9%) and decreased in six (6.8%) eyes. The cause of decreased vision was development of cataract in four eyes and ERM in two eyes.

Table 6 shows factors associated with poor visual recovery defined as final vision <6/60 in successfully re-attached macula-off detachments. The only factor significant on both uni- and multivariate analysis was preoperative BCVA ≤ 3/60.

Discussion

Certain characteristics of our population matches those of other studies, for instance mean age in our study was 36.17 years which correlates with other Indian studies (38 years).[12] However, PVR (grade B or worse) was less frequent in our study (5.6%) than others.[13] This could be due to difference in follow-up duration; however, reattachment rates were nearly same. Since both (drainage and non-drainage) procedures exhibit similar retinal re-attachment rates,[2-5] advantage with non-drainage procedure seems to be in avoiding intra- and postoperative complications. These complications are major causes of unsuccessful surgical outcome.[14] In our study, most common postoperative complication was serous CD in 30 (9.8%) eyes, all of which developed one or two days after surgery and resolved over a span of two to three weeks with topical and systemic steroids. Recent evidence suggested the frequency of CD after SB to be 2.4%.[15] The reasons for the increased incidence of CD, in our series, were not very clear. However, since 7 (23.3%) eyes had received intravitreal air and/or saline injection (in contrast to 15.7% of total eyes), hypotony could have been a primary cause. Twenty three (76.7%) eyes that developed post-operative

CD had >2 quadrants of RD and 9 (30%) had placement of >2 quadrants of scleral buckle. Post-operatively, raised IOP was controlled by topical anti-glaucoma medications or systemic carbonic anhydrase inhibitors, whenever necessary. Diplopia was present in 3 (1%) eyes, all of which had placement of ≥2 quadrants of scleral buckles (including multiple buckles in 2 cases). All 3 cases were managed with prescription of appropriate prismatic glasses. The rate of post-SB diplopia is much lower in our study than that observed in other studies (5-25%).[16]

Table 5: Factors associated with fi nal anatomical failure after treatment with non-drainage scleral

buckling surgery

A. Univariate analysis A. Multiple logistic analysis

Final P Odds ratio (95% CI) P Odds ratio (95% CI)

Success Failure

PVR* (grade B or worse) 11 6 0.002 3.400 (1.643-7.037) 0.049 4.048 (1.006-16.280)

IOP† <10 mm Hg 52 16 0.001 2.889 (1.560-5.350) 0.01 3.348 (1.335-8.395)

Suspect/no break 7 3 0.056 2.845 (1.039-7.790) 0.019 7.374 (1.385-39.251)

Preoperative VA‡ <3/60 111 25 0.001 2.841 (1.450-5.565) 0.967 0.980 (0.381-2.524)

Pseudophakia/Aphakia 62 14 0.038 1.926 (1.038-3.572) 0.234 1.847 (0.673-5.068)

Macula-detached RD** 163 27 0.089 1.832 (0.893-3.756) 0.943 1.040 (0.357-3.028)

Duration >1 month 89 8 0.107 0.549 (0.259-1.165) 0.642 1.259 (0.477-3.320)

Age >60 years 32 9 0.030 0.464 (0.235-0.915) 0.583 0.726 (0.232-2.275)

*PVR: Proliferative vitreo-retinopathy, †IOP: Intraocular pressure, ‡VA: Visual acuity, **RD: Retinal detachment

Table 6: Factors associated with poor visual

recovery* in 34 eyes after treatment with

non-drainage scleral buckling surgery

Univariate analysis

Final VA*

>6/60

Final VA*

<6/60

P Odds ratio (95% CI)

Preoperative

VA†<3/60

71 29 <0.001 4.568 (1.686-12.375)

Suspect/no

break

1 2 0.046 3.402 (1.434-8.074)

Duration >1

month

48 14 0.534 1.222 (0.651-2.2294)

Pseudophakia/

Aphakia

32 6 0.435 0.731 (0.326-1.638)

*VA: Visual acuity

Figure 2: Comparison between pre- and post-operative (at 6 weeks) visual acuity

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Rishi, et al.: Non-drainage scleral buckling

Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014 59

We also evaluated the relationship of SRF absorption to various pre- and intraoperative factors. The only case in our study in which SRF absorption took more than six months was a highly myopic (>-13D) eye. Overall, however, myopia was not significantly associated with delayed SRF absorption. SRF absorption pattern has been correlated with patient’s age,[5,17] duration of RD,[5,18,19] extent of RD,[5] sub-retinal precipitates[19] and post-operative IOP.[20] In our study, we did not find a significant association of age of RD or age of patient with delayed SRF absorption (as also suggested by Chignell et al.).[14] In our series, re-detachment occurred in nine (3%) eyes, of which seven (2.3%) were classified as early re-detachments (occurring between six weeks and six months) and two (0.7%) as late re-detachments (occurring after six months). The major cause of primary failure, as well as early re-detachment, was PVR and of late re-detachment was new retinal break. Thus, final reattachment rate was 88.2% at last follow-up. PVR (grade B or C), IOP < 10 mm Hg and the inability to find retinal break were significantly associated with final anatomical failure.

In the present study, primary reattachment rate was 91.2% by six weeks, which shows a good agreement with other studies.[21] Schwartz et al. reported final reattachment rate of 95%.[22] Jalali et al. found a success rate of 80.3%, commonest cause of failure being missed break in 32.4%.[23] Haritoglou et al. reported a primary success rate of 84.7%, being 89.7% in phakic patients and 73.9% in pseudophakic patients.[24] In our study, anatomical success rate was 90.4% in phakic, 82% in pseudophakic and 80% in aphakic eyes. Sasoh et al. reported primary reattachment rate of 91.2% over follow-up of 10 years.[21]

It may appear that the duration of postoperative macular detachment is longer in eyes operated upon by non-drainage technique than in those operated with SRF drainage. Hence, the former technique might have visual results worse than the latter. However, as seen in Figure 1, on evaluating the visual outcomes, results were not significantly different with early or late absorption of SRF. Hilton et al. also reported no difference in the final visual acuity in both the drainage and non-drainage groups.[3]

Primary functional success was achieved in 286 (93.5%) eyes in our study. Overall, there was a significant improvement between pre- and postoperative visual function in re-attached cases as also noted by other studies.[13] On evaluating, factors associated with poor visual recovery (PVR), though a major factor for anatomical failure was not associated with PVR. Of 433 eyes undergoing pars plana vitrectomy/SB, Jalali et al. reported that although PVR and prolonged duration of RD were not independent risk factors for anatomical failure, they did reduce the probability of good visual recovery.[23] However, since Jalali et al. included patients that underwent both pars plana vitrectomy and SB, our results cannot be compared with their findings.[23]

For RRD, SB surgery has the highest single operation success rate.[25,26] Few studies in the past have tested the suitability of

solid silicon materials for SB. To the best of our knowledge, this is the largest surgical series among patients who underwent non-drainage SB surgery using solid silicone elements. This surgical technique is reasonably safe, economically viable and highly efficacious. Major limitations of our study were its retrospective nature, inter-observer agreement (many different surgeons) and short follow-up.

Solid silicone elements are effective in non-drainage SB surgery. Retinal reattachment rates are comparable to silicone sponges but with lower rates of complications. Careful case-selection is vital.

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Cite this article as: Rishi P, Rishi E, Gupta A, Mathew CS, Shah BJ. Non-drainage scleral buckling with solid silicone elements. Oman J Ophthalmol 2014;7:55-60.Source of Support: Nil, Confl ict of Interest: None declared.

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