Surgical options

With technology and repair techniques rapidly evolving in recent years, surgeons now have a range of safe and successful surgical options available for the management of primary retinal detachments (RD), according to José García-Arumí MD. “The three principal techniques – pneumatic retinopexy, scleral buckling and pars plana vitrectomy (PPV) – are all used successfully for the treatment of primary retinal detachments. However, what we do need are more randomised clinical trials to determine the best procedure for particular indications,” Professor García-Arumí told delegates attending the 8th EURETINA Winter Meeting in Budapest. The key to successful surgery lies in rigorous preoperative evaluation, said Prof García-Arumí. “It is critical to identify retinal breaks with meticulous planning preoperatively and then employ skilful surgery to remove traction and seal retinal breaks. The choice of the surgical technique and tamponade agent is related with the experience of the surgeon and the severity of the case,” he added. BROAD OVERVIEW In a broad overview of the various techniques available for RD surgery, Prof García-Arumí said that pneumatic retinopexy offers a lower rate of retinal reattachment with a single operation and with limited indications. “It is not applicable in many types of retinal detachment and is less effective in aphakic or pseudophakic patients. It is also less employed in Europe and it seems to be less used in the United States as well. An American Society of Retina Specialists survey in 2017 showed that pneumatic retinopexy as preferred primary procedure for RD has decreased in the last 10 years,” he said. While several studies have confirmed similar results for scleral buckling and PPV, the indications for both procedures are not identical, said Prof García-Arumí. “Scleral buckling works well in phakic patients, inferior tears, young patients, myopic patients with posterior hyaloid detachment, superior tears in fresh RD, retinal dialysis cases and proliferative vitreoretinopathy (PVR) degree A or B. It is always important to check the status of the vitreous beforehand,” he said. Scleral buckling The advantages of scleral buckling include the fact that there is no associated lens trauma or iatrogenic breaks, while drawbacks include issues related to increased myopia, image disparity, double vision in myopic patients, red eye, discomfort, possibility of extrusion and problems related with drainage and suture, added Prof García-Arumí. Advantages of PPV include the fact that it induces no refractive changes, there are no floaters and it less painful than scleral buckling procedures. While PPV is growing in popularity as a first-line procedure for primary RD, especially in pseudophakic patients, it comes with its own complications, including postoperative cataract formation in patients older than 50-55, long-term IOP increase, retained perfluorocarbon liquids and macular retinal folds, said Prof García-Arumí. “There is also probably more intraocular inflammation and epiretinal membrane formation with PPV and it is more expensive than scleral buckling,” added Prof García-Arumí. The surgical indications for combined scleral buckle and PPV surgery include retinal detachments with inferior breaks, pseudophakic/aphakic patients, early or established PVR, multiple breaks in three or more quadrants, and extensive detachment cases in which breaks are difficult to detect, or those with giant tears, he said. For PVR cases, a scleral buckle will sometimes relieve the traction, said Prof García-Arumí, and is particularly indicated in circumferential contraction. In terms of the choice of retinal tamponade agent, there is no real consensus as to what works best for particular types of RD. “The only clear conclusion we can draw at the moment is that tamponade agent is related with the experience of the surgeon and the severity of proliferative disease present,” he said. Looking at current trends in RD surgery, Prof García-Arumí said that a recent study by McLaughlin et al. looking at Medicare patients in the United States from 2000 to 2014 confirmed the increase in PPV procedures. “Scleral buckling declined from 6,502 procedures in 2000 to 1,260 procedures in 2014, while vitrectomy increased from 13,814 surgeries in 2008 to 19,288 surgeries in 2014. The distribution in 2014 was 83% vitrectomy, 5% scleral buckling and 12% pneumatic retinopexy. Cryotherapy declined across all indications,” he added. José García-Arumí: 
jgarcia.arumi@gmail.com