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Original Clinical Study

Urgent Vitrectomy/Phacovitrectomy for Bullous Macula-Off Retinal Detachment

Implications for Optimal Timing of Surgery

Kikushima, Wataru MD*†; Imai, Akira MD*; Miyahara, Teruyoshi MD, PhD*; Kurokawa, Toru MD, PhD*; Murata, Toshinori MD, PhD*

Author Information
Asia-Pacific Journal of Ophthalmology: January/February 2014 - Volume 3 - Issue 1 - p 36-40
doi: 10.1097/APO.0b013e3182a1a7c6
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Abstract

Retinal detachment (RD) is a vision-threatening disorder, but a good visual outcome can be expected if the affected eye is treated before RD involves the fovea. Consequently, macula-on RD is generally considered to be a surgical emergency to preempt foveal detachment.1,2 Unfortunately, more than two thirds of new patients already have macula-off RD upon arrival at the outpatient clinic of operating facilities.3–5 A prolonged duration of macular detachment (DMD) has been considered to result in severe hypoxic photoreceptor damage and resultant visual acuity (VA) loss.3,6 The term macula-off RD usually refers to RD with foveal involvement in the clinical setting.

The effect of DMD on postoperative VA has commonly been evaluated for scleral buckling operations using 2 outcome measures: mean postoperative VA and ratio of patients achieving good postoperative VA such as 20/40. Although there are many ophthalmologists who believe that macula-off RD requires emergency surgery to obtain a good visual outcome, the reported cutoff time after which mean postoperative VA decreases sharply ranges widely from 1 day3,6,7 to about 1 week,3,8–12 to 2 weeks,13,14 to 2 months,15,16 to up to half a year.17 Recently, Hassan et al9 and Diederen et al8 addressed this wide discrepancy in DMD cutoff time by emphasizing the importance of strict criteria to exclude factors that may otherwise influence postoperative best corrected VA (BCVA), such as media opacity and coexisting ocular disorders, including macular hole, vascular occlusion of the retinal vessels, cystoid macular edema, and proliferative vitreoretinopathy (PVR). They8,9 used the same inclusion criteria such as primary bullous macula-off RD, VA of 20/200 or less, and only eyes of patients who could time the onset of significant visual loss accurately to a specific 24-hour period and reported superior VA recovery in an acute group (DMD ≤10 days) compared with subacute (11 days ≤ DMD ≤ 6 weeks) and chronic groups (DMD >6 weeks). The majority of ensuing literature regarding DMD cutoff time generally supports their results, stating that scleral buckling surgery for macula-off RD should be performed within 7 to 10 days to avoid significant worsening of mean postoperative VA.12,18–21 Hassan’s9 and Diederen’s8 groups also found that eyes with DMD of 10 days or less achieved a postoperative 20/40 VA at frequencies of 59% and 71%, respectively, which decreased to 32% and 27% when DMD fell between 11 days and 6 weeks.8,9

Whereas scleral buckling has long been the treatment of choice for repair of uncomplicated RD,22–27 an increasing number of ophthalmologists are using vitrectomy as the first line of treatment for many kinds of RD.6,25,26,28–39 For example, Hwang34 reported that 11% of RD cases in Medicare were treated with stand-alone scleral buckling in 2009, whereas 74% were treated with vitrectomy. In this study, we used vitrectomy with a wide viewing system as the primary option for the treatment of macula-off RD. In pseudophakic eyes with macula-off RD treated with vitrectomy, Speicher et al29 reported that a shorter DMD was predictive of higher postoperative VA, whereas Campo et al28 reported that DMD had little effect on postoperative VA. Because the inclusion criteria in these 2 studies were simply pseudophakic eyes with RD, their results could not be directly compared with those of earlier studies using scleral buckling under more extensive criteria.8,9 To our knowledge, the golden time for vitrectomy of macula-off RD has not been investigated using the strict criteria as described above to make DMD the single major variable. The present study aimed to determine the DMD cutoff time after which mean postoperative VA outcome becomes significantly worse for bullous macula-off RD treated with vitrectomy in pseudophakic eyes or with phacovitrectomy in phakic eyes with visually significant cataracts. To verify if the DMD cutoff time of 7 to 10 days established in studies using scleral buckling8,9,12,20 was also valid for vitrectomy/phacovitrectomy, we used the same extensive inclusion criteria and analytical methods as those used in reports of Hassan et al9 and Diederen et al.8 In addition to mean postoperative VA, we investigated the DMD cutoff times for obtaining set postoperative BCVA values of 20/40 in patients with bullous macula-off RD treated with vitrectomy/phacovitrectomy.

MATERIALS AND METHODS

The ethics committee of Shinshu University approved this study, which was conducted in accordance with the tenets of the Declaration of Helsinki. Informed consent was obtained from all subjects.

The inclusion criteria are as follows:

  • (1) Eyes having primary, uncomplicated bullous macula-off RD with a VA of 20/200 or less;
  • (2) patients 50 years or older who regularly used reading glasses; and
  • (3) patients who were able to recount their precise ocular history from which we could estimate the onset of significant central vision loss to a specific 24-hour period; a central vision loss indicated foveal detachment.

The exclusion criteria are as follows:

  • (1) eyes with prior or coexistent ocular diseases, such as macular hole, glaucoma, age-related macular degeneration, or PVR grade C; poor postoperative BCVA could not be attributed solely to macula-off RD in these eyes;
  • (2) patients younger than 50 years who did not require reading glasses. These patients were treated with scleral buckling;
  • (3) eyes with prior ocular surgery apart from uncomplicated cataract extraction;
  • (4) eyes with complicated RD, such as macula-hole RD in highly myopic eyes and RD associated with retinoschisis;
  • (5) eyes that showed a recurrence of RD; and
  • (6) eyes followed for less than 6 months.

Participants

We reviewed the medical records of 282 patients with rhegmatogenous RD who were treated during a recent 2-year period (2010–2011) at Shinshu University Hospital in Matsumoto, Japan. Of these, 126 patients with bullous macula-off RD met the strict inclusion/exclusion criteria described above, comprising 46 pseudophakic eyes that underwent vitrectomy and 80 phakic eyes that underwent phacovitrectomy. Forty-five patients (36%) were female, and 81 patients (64%) were male. Mean patient age was 64 ± 16 years (range, 42–89 years). Symptoms at presentation included floaters, visual field defects, distorted vision, and loss of vision. Our exclusion criteria applied to macula-on RD (105 eyes), PVR grade C (8 eyes), coexistent macular hole (7 eyes), redetachment (5 eyes), uncertain DMD (8 eyes), and treatment with scleral buckling (23 eyes).

Control Subjects

Forty-six of 105 macula-on eyes served as controls, which consisted of 22 pseudophakic eyes treated with vitrectomy and 34 phakic eyes with VA of less than 20/40 due to cataracts that were treated with phacovitrectomy. The final judgment of macula on/off status was based on observation under the operation microscope.

Surgical Intervention

To reduce the risk of recurrent RD due to traction by residual peripheral vitreous, patients 50 years or older who regularly used reading glasses were suggested to undergo vitrectomy with concomitant phacoemulsification cataract surgery (phacovitrectomy) followed by intraocular lens implantation as the first line of treatment if they had mild cataract. We believe that reducing the risk of recurrent RD by thorough shaving at the vitreous base with cataract removal is more important than sparing a lens that has already lost much of its accommodating function; less extensive anterior vitrectomy in phakic patients to avoid direct damage to the natural lens may result in a higher rate of recurrent RD.28

We performed scleral buckling on patients in whom it was preferential to spare the lens, as scleral buckling provides better visual outcome in phakic eyes than does lens-sparing vitrectomy.31 Patients were generally treated with scleral buckling if they were younger than 50 years, did not require reading glasses, or had restricted RD peripheral to the equator. However, if a preoperative fundus examination to locate the causative retinal tear was hindered by a cataract or vitreous hemorrhage, vitrectomy/phacovitrectomy was performed regardless of the patient’s age. Bullous macula-off status in these eyes was confirmed using B-mode ultrasonography.

Data Collection

Postoperative data collected included retinal attachment status at each postoperative visit, reoperation, and postoperative BCVA. Subjects continued periodic monitoring at nearby eye clinics after completing a 2-month follow-up at our hospital since the risk of RD recurrence drops significantly 2 months after the primary operation.40–42 To update the status of eyes for assessment of BCVA, intraocular pressure, and other remarkable findings, we sent written questionnaires and made phone calls to all related eye clinics. Consequently, all eyes included in this study completed a minimum 6-month follow-up period.

Statistical Analysis

The evaluation of VA was conducted in decimal VA in the present study. Mean VA and SD were calculated using logarithm of the minimal angle of resolution (logMAR) values and then converted back to Snellen or decimal equivalents.43 Categorical variables were analyzed using Fisher exact test or the χ2 test. Comparisons between preoperative and postoperative VA were made using the Mann-Whitney U test or 1-way analysis of variance (Kruskal-Wallis test). P ≤ 0.05 was considered to be statistically significant.

RESULTS

Reattachment Rate

The primary reattachment rate for macula-off RD eyes treated with vitrectomy/phacovitrectomy was 96% (126/131). Five eyes experienced redetachment within 6 months of the primary surgery, but anatomical success was achieved after a single reoperation. Consequently, 126 patients were analyzed for the relationship between DMD and postoperative BCVA. In the 56 eyes with macula-on RD treated with vitrectomy or phacovitrectomy, the primary success rate was 98% (55/56). The anatomical success rate did not significantly correlate with the preoperative or intraoperative factors of age, sex, refractive error, location or extent of rhegmatogenous RD, location or number of retinal breaks, or method of surgery.

Changes in Mean Postoperative Visual Acuity Depending on Duration of Macular Detachment

The preoperative mean VA in eyes with bullous macula-off RD treated with vitrectomy or phacovitrectomy was 20/260 (1.09 ± 0.65 logMAR), which improved to 20/85 (0.63 ± 0.79 logMAR) postoperatively. The mean postoperative BCVA in the acute (DMD ≤10 days) group (20/46: 0.36 ± 0.34 logMAR) was significantly better than those in the subacute (11 days ≤ DMD ≤ 6 weeks) (20/85: 0.63 ± 0.40 logMAR, P = 0.006) and chronic (DMD >6 weeks) groups (20/68: 0.53 ± 0.45 logMAR, P = 0.009), which was comparable to the results of Hassan et al9 and Diederen et al8 using scleral buckling (Table 1). On the other hand, the mean postoperative VA of eyes with macula-on RD treated with vitrectomy or phacovitrectomy was 20/21 (0.03 ± 0.19 logMAR), which was significantly better than that of the eyes in the acute group (P = 0.001), confirming the importance of surgery while the macula is on.

TABLE 1
TABLE 1:
Effect of Duration of Macular Detachment on Postoperative VA

Ratio of Eyes Attaining Postoperative 20/40 or 20/20

Several reports have set 20/40 as a target postoperative VA and investigated its relationship with DMD with regard to scleral buckling.5,11,35 Accordingly, we investigated the relationship between DMD and the ratio of eyes that achieved visual recovery to 20/40 and 20/20 for vitrectomy/phacovitrectomy (Fig. 1).

FIGURE 1
FIGURE 1:
Relationship between DMD and the ratio of eyes achieving postoperative VA levels of 20/40 and 20/20.

The ratios of eyes attaining a postoperative VA of 20/40 in relation to DMD were 93% (macula-on, 52/56), 87% (1 day, 13/15), 88% (2 days, 14/16), 64% (3 days, 7/11), 60% (4 days, 9/15), 44% (5 days, n = 9), 43% (6 days, n = 7), 56% (7 days, n = 9), 40% (8 days, n = 2/5), 50% (9 days, 1/2), 50% (10 days, 1/2), and 28% (>11 days, n = 8/28). Interestingly, the frequency of eyes with a postoperative VA of 20/40 or better did not show a statistically significant difference between macula-on eyes and macula-off eyes as long as DMD was 2 days or less (P = 1). This decreased sharply when DMD exceeded 2 days (P = 0.008), but plateaued at approximately 40% until DMD reached 10 days. The incidence of achieving a postoperative VA of 20/20 based on DMD was 4 eyes (27%, n = 15, 1 day), 2 eyes (13%, n = 16, 2 days), 1 eye (9%, n = 11, 3 days), and no eyes with a DMD of 4 days or more. There were no statistically significant differences among the DMD times in achieving postoperative 20/20 vision because our sample size could not provide adequate power to detect small day-to-day differences during this period. On the other hand, 71% (40/56) of eyes with macula-on RD (DMD = 0 days) achieved 20/20 vision, which was significantly higher than eyes with a DMD of 1 day (P = 0.0024).

DISCUSSION

Comparably to previous studies using scleral buckling,8,9 the DMD cutoff time for macular-off RD treated with vitrectomy/phacovitrectomy was 10 days in this study. Contrary to our presumptions, however, urgent surgeries seeking a shorter DMD appeared to have a relatively minor effect on improving mean postoperative BCVA outcome. On the other hand, when we evaluated VA outcomes according to the ratio of eyes that achieved a BCVA of 20/40, deterioration became prominent when DMD exceeded 2 days.

To perform statistical analysis, most studies have used mean VA when determining the DMD cutoff time after which postoperative VA would worsen significantly. However, surgeons tend to evaluate the results of their RD surgeries based on the percentage of individuals who are satisfied with their postoperative BCVA outcome rather than the mean VA of all patients; for instance, good outcomes have been defined as of 20/405,8 or 20/50.44 We observed that only 5.6% (7 of 126) eyes with a preoperative VA of 20/200 or less due to bullous macula-off RD had regained a BCVA of 20/20 at 6 months of follow-up. No apparent DMD cutoff time for 20/20 vision was determined because we could not obtain a statistically significant difference because of insufficient patient numbers. On the other hand, 71% (40/56) of eyes with macula-on RD attained a postoperative VA of 20/20, confirming the urgency of RD surgery before it involves the fovea.

Most interestingly, the ratio of eyes attaining a postoperative BCVA of 20/40 was similarly high at approximately 90% for both macula-on and macula-off eyes as long as DMD was 2 days or less. This ratio dropped to 60% after 3 days and 40% after 5 days and then plateaued until DMD exceeded 10 days. We thus found that DMD length had adverse effects on the ratio of eyes that regained a postoperative BCVA of 20/40 when exceeding 2 days, despite having little influence on mean postoperative BCVA as long as it was within 10 days.

To achieve good postoperative VA recovery, primary reattachment rate may be the most important factor, which was evident in 96% of the eyes treated with vitrectomy. In pseudophakic RD, preoperative identification of all causative peripheral retinal breaks prior to surgery is often hampered by capsular bag opacity.22,28 In a series of pseudophakic RD cases treated with scleral buckling, retinal breaks were not identified in 20% of subjects.27 Missed peripheral retinal breaks can result in failure to achieve primary anatomical success, which most significantly reduces the chance of a good VA outcome.6,45 On the other hand, in vitrectomy for pseudophakic RD, all causative peripheral retinal breaks can be identified under direct examination using an operating microscope by scleral indentation, even if there is capsular bag opacity.

One drawback of vitrectomy is a higher incidence of postoperative cataract progression as compared with scleral buckling.31 Schneider et al36 reported that 62.5% of patients required cataract surgery after lens-sparing vitrectomy for RD, whereas this rate was 33% after scleral buckling.26,36 Phacovitrectomy provides a solution to this problem. To eliminate the influence of rapid cataract worsening after vitrectomy, only pseudophakic RD eyes treated with vitrectomy and phakic RD eyes with cataracts treated with phacovitrectomy were included in this study.

There are several shortcomings of this trial. First, it was retrospective and nonrandomized. Second, the determination of DMD was dependent on patient memory, which could have been imprecise as DMD became longer. Third, we did not directly measure RD height using 3-dimensional B-scan ultrasonography. Ross et al12 reported that the preoperative height of macular detachment was the most important factor in VA recovery and was inversely correlated with final VA outcome. However, our study included only eyes with bullous macula-off RD to exclude those with shallow RD that could possibly show good visual outcome independently of DMD. Lastly, the number of patients enrolled was relatively small, especially in the subdivisions of subacute and chronic groups, although the numbers were comparable to those of previous studies using scleral buckling.8,9

In summary, the results of present study suggest that the DMD cutoff time for bullous macula-off RD treated with vitrectomy/phacovitrectomy after which postoperative mean BCVA decreases sharply is approximately 10 days. This is comparable to previous studies on scleral buckling.8,9,12,18–21 On the other hand, to achieve a good postoperative VA (20/40), urgent surgery with a DMD of 2 days or less is desirable. Further investigation in larger cohorts is necessary to clarify the relationship between DMD and postoperative VA in eyes with bullous macula-off RD treated with vitrectomy/phacovitrectomy.

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Keywords:

retinal detachment; vitrectomy; phacovitrectomy; best corrected visual acuity; duration of macular detachment

© 2014 by Asia Pacific Academy of Ophthalmology