Scleral buckling versus vitrectomy for primary rhegmatogenous retinal detachment - PDF Document

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  1. Major Review Scleral buckling versus vitrectomy for primary rhegmatogenous retinal detachment Aditya Maitray1, V Jaya Prakash2and Dhanashree Ratra3 1Fellow, Sri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, India Introduction Retinal detachment (RD) surgery is the most common retinal surgery performed. RD can be repaired either by scleral buckling (SB) or pars plana vitrectomy (PPV). Pneumoretinopexy, laser delimitation or observation can be done in selected cases. The decision to perform SB or vitrectomy depends on various factors, including age of the patient, duration and extent of RD, presence of proliferative vitreoretinopathy (PVR) changes, the number, location and size of retinal breaks and the lens status. Other factors which influence the decision are availability of operating room equipment or staff, various patient factors (especially expected compliance with positioning after surgery) and surgeon preference.1 about a decade ago, SB was the preferred proced- ure, but there is a general trend towards vitrec- tomy with the development of newer technology. There are several retrospective and prospective studies which compare SB and vitrectomy for primary RD. The anatomical and visual outcomes following retinal reattachment surgeries reported in the recent peer-reviewed literature will be dis- cussed in this article. include increased postoperative morbidity like pain and periorbital oedema, drainage-related complications like vitreoretinal incarceration, sub- retinal haemorrhage and choroidal detachment, diplopia due to muscle restriction, chorioretinal circulatory disturbances, refractive changes (typic- ally axial myopia), epiretinal membrane forma- tion, buckle intrusion, extrusion and infection. Subretinal fluid may take time to absorb in case of non-drainage procedure delaying anatomical recovery and resulting in poorer final visual outcomes. 2Associate consultant, Consultant, Sri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, India 3Senior Consultant, Sri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, India Pars plana vitrectomy The major advantage of PPV over SB is the improved internal search for breaks with micro- scopic visualization of peripheral fundus by scleral indentation and internal illumination. Other major advantage usually cited is the direct elimination of vitreous traction and removal of the vitreous leading to elimination environment.3 It can help to clear media opacity, can address very posterior breaks and giant retinal tears and allow use of PFCL, internal drainage of subretinal fluid and intraoperative With the development of improved visualization systems and smaller gauge surgical techniques, the success rate of vitrectomy has improved con- siderably. The potential problems with vitrectomy are the increased rate of cataract formation, iatro- genic breaks, requirement for postoperative posi- tioning and higher cost. Table 1 summarizes the basic differences between the two techniques. Based on the above differences between SB and vitrectomy, it is obvious that a few cases like localized detachment with single or neighbouring breaks are ideal for SB and complicated cases like PVR grade C or D, giant retinal tears, very posterior breaks and macular holes are better treated with vitrectomy. However, for a vast majority of cases that lie in between these two extreme scenarios, there exists some confusion regarding which surgical modality would give the best outcome. This group com- prised about 30% of all primary rhegmatogenous RDs in the SPR recruitment study.4 ambiguous cases which include patients with mul- tiple breaks in different quadrants, bullous rheg- matogenous RDs, breaks extending central to the equator, breaks with marked vitreous traction and rhegmatogenous RDs with unclear hole situations Until Correspondence: Dhanashree Ratra, Senior Consultant, Shri Bhagwan Mahavir Vitreoretinal Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India. Email: drdad@snmail.org of PVR-stimulating retinal attachment. Scleral buckling SB provides target-oriented retinal attachment. It is ideally suited for detachments with anterior retinal breaks and dialysis. It is also a very rewarding surgery for suitable paediatric RDs wherein PVD induction during PPV is a challenge. It is efficacious for both superior and inferior breaks, does not cause cataract, does not require postoperative positioning, unless gas or air is injected, and has a high single-surgery success rate (SSSR). Success rate can be further improved by meticulous preoperative and intraoperative search for breaks. Chandelier-assisted SB has also been described that can allow direct intraoperative visualization of peripheral retina under magnifica- tion.2On the other hand, patients with giant retinal breaks (GRTs), posterior breaks, PVR worse than grade B, thin sclera, glaucoma drainage device, previous strabismus surgeries and media haze (e.g. vitreous haemorrhage) precluding visu- alization of peripheral retina are not ideally suited for scleral bucking procedures and respond more favourably to PPV. The main reasons for failed buckle surgery are missed breaks, fishmouthing, inadequate buckling effect, development of new retinal breaks and PVR. The drawbacks with SB Certain 10 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 |

  2. Major Review Table 1: SB versus PPV: comparison Scleral buckle PPV Mechanism of vitreous traction relief Internal tamponade Efficacy for superior/inferior breaks Efficacy in the presence of PVR > grade B Postoperative morbidity* Postoperative positioning SSSR Other advantages Indirect/passive Direct Nil Equal Silicone oil/gas Better for superior breaks Less Better More Not required 90–95% Can support missed breaks Allows air travel Effective for retinal dialysis No cataract formation Refractive changes Ocular motility disturbance Vitreoretinal incarceration Subretinal/suprachoroidal haemorrhage Migration/exposure of buckle elements Macular pucker Less Required 85–90% Clears media opacities Effective for giant retinal tears, posterior breaks Potential complications Cataract progression Raised intraocular pressure Iatrogenic breaks Miscellaneous disadvantages Moisture condensation on silicone IOLs during fluid–air exchange Restricted air travel in immediate postoperative period if gas tamponade used Expensive *Pain and periorbital oedema in immediate postoperative period. (no break or not all breaks could be identified on examination before surgery) require a lot of debate. We searched PUBMED for the following terms: ‘retinal detachment’, ‘scleral buckle’ & ‘vitrectomy’ and finally analyzed recent relevant studies (pub- lished after year 2000) comparing SB and vitrec- tomy with minimum of 6 months mean follow-up and a minimum sample size of 30 eyes. of macular detachment, height and duration of macular detachment (DMD) and amount of pre- existing cataract. The other reported outcomes were the number of retinal procedures/reopera- tions, the redetachment rate and complications like postoperative PVR rate, raised intraocular pressure, epiretinal membrane and cataract devel- opment (in phakic patients). Retrospective studies Table 2 summarizes the recent retrospective com- parative studies between SB and PPV for rhegma- togenous RD. Most of the retrospective studies showed no difference in anatomical and functional outcomes between SB and PPV However, Park et al. have reported that PPV might show better visual outcomes compared with SB in older phakic patients, the final anatomical out- comes still remaining comparable. This may be due to the presence of PVD and performing com- bined cataract surgery along with PPV whenever required.12 In pseudophakic eyes with uncomplicated RDs, initial and final anatomical outcomes have been reported to be better with PPV alone/PPV com- bined with SB compared with SB as per a meta-analysis of comparative retrospective studies Outcomes The most commonly reported anatomical out- comes in these comparative trials between SB and PPV for primary rhegmatogenous RDs include single-surgery success rate (SSSR: defined by most studies as an attached retina at final follow-up after a single surgery) and final anatomical success rate (defined as an attached retina at final follow-up after ≥1 surgical interventions). The functional outcomes studied include change in best-corrected visual acuity (BCVA, in terms of logarithm of the minimum angle of resolution [LogMAR] or Snellen’s acuity expressed as the proportion of study eyes achieving final vision better than 6/60 −6/18, depending on the study criteria). Apart from the surgical technique used, the visual acuity results may also be affected by several other factors like the presence or absence 2).5–13 groups (table 11 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 |

  3. 12 Major Review Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | Table 2: Study SB versus PPV: retrospective studies Type of surgery No. of eyes (follow-up) SSSR (p*) Visual outcome (p*) Complications (p*) Comments Oshima et al. (2000)8, Primary uncomplicated macula off RD Preoperative VA, IOP and DMD best predictors of postoperative visual recovery in both groups SB 55 (24 months) 91% (final reattachment rate 100%) 0.42 LogMAR Iatrogenic breaks 4% Subretinal/vitreous bleeding 5% Cataract progression 12% ERM formation 7% PVR 3.8% Ocular hypertension 0 Iatrogenic breaks 4% (p=0.24) Subretinal/vitreous bleeding 2% (p=0.62) Cataract progression 64% (p<0.001) ERM formation 2% (p=0.37) PVR 4% (p>0.99) Ocular hypertension 2% (p>0.99) PPV group had better visual recovery in patients with preoperative visual acuity <0.1, DMD >7 days and preoperative IOP <7 mmHg PPV 47 (24 months) 91% (final reattachment rate 100%) 0.45 LogMAR at 24 months (p=0.85) Miki et al. (2001)9, Uncomplicated RD from flap tears in superior quadrant SB 138 (6 months) 92% (final 100%) Initial failure in 11 eyes due to malpositioned buckle (seven eyes multiple tears and four posterior large flap tears) Subretinal haemorrhage 4.3% Penetrating suture 2.6% Ocular motility defect 5.1% ERM 2.2% PVR 0 Postoperative cataract 0 Initial anatomical failure in seven eyes (new tears five eyes, reopening of old tears in two) Subretinal haemorrhage 0 Penetrating suture 0 ERM 2.3% PVR 3.4% Lens trauma (6.9%) Iatrogenic breaks (9.2%) Postoperative cataract 20.7% (p<0.05) Eyes undergoing PPV+encircling band achieved 100% SSSR compared with eyes treated with PPV alone (86.3%). Vitrectomy appeared to have a better success rate 96.6% in case of multiple superior breaks compared with SB (69.9%) but not statistically significant PPV 87 (6 months) 92% (final 100%) - Huang et al. (2013)10, Macula off RDs SB 32 (8 weeks) Mean change in LogMAR 0.4± 0.8 ERM on SDOCT in 15.6% Residual SRF at macula on SDOCT in 81.3% in SB group versus 19.2% in the PPV group at 8 weeks (p<0.05) PPV faster for macular recovery in macula off RDs No difference in structural changes at macula on SDOCT between two groups PPV 26 (8 weeks) Mean change in LogMAR 0.7± 0.8 (p<0.05) 0.29–0.13 (p=0.001) ERM on SDOCT in 19.2% (1.0) SB

  4. Kobashi et al. (2014)11, Uncomplicated RD 271 (6 months) 260 phakic, 11 pseudophakic 93.7% (final success rate 100%) Needle perforation 0.4% Reopening of original break 3% New break causing redetachment 3.8% PVR 0.4% Macular pucker 0.4% CME 0.7% Choroidal detachment 0.7% Transient diplopia 0.7% Iatrogenic breaks 7.7% Reopening of original break 2.2% New break causing redetachment 1.1% PVR 0.4% Macular pucker 0.7% CME 0.4% Pupillary block 1.1% In the SB group, eyes with macula-off status associated with a lower success rate (p=0.002). Although break location and lens status had no significant effect on success rates in either group. All phakic eyes in the PPV group underwent combined cataract surgery PPV 271 (6 months) 228 phakic and 42 pseudophakic 96.3% (final success rate 100%) 0.68–0.14 (p<0.001) Erakgun et al. (2014)12, Uncomplicated RD with mild vitreous haemorrhage SB 38 (6 months) 79% 0.55 Subretinal haemorrhage (5.2%) Macular pucker (7.8%) Cataract progression (13%) PVR grade B or worse (10.5%) Subsequent cataract sx (5.2%) Ocular hypertension 0 Iatrogenic breaks (10%) Macular pucker 5% (0.6) Cataract progression 35% (0.02) Lens damage (5%) PVR grade B or worse 5% (0.4) Cataract sx 20% Ocular hypertension 2.5% Phakic eyes with mild rhegma- related vitreous haemorrhage with visible peripheral fundus selected. SSSR better in the PPV group, final anatomical success 100% in both groups Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | BCVA at 3 months better in the PPV group but similar in two groups at 6 months PPV 40 (6 months) 95% (p=0.03) 0.6 (p=0.9) Rush et al. (2014)13, Medium complexity RD 65.12% ≥20/40 SB 121 eyes (6 months) 87.6% No difference in overall outcomes between different techniques. No difference in anatomical (p 0.11, 0.78) or visual outcomes (0.63, 0.55) with the three techniques between phakic andpseuodphakic lens status PPV 444 eyes C3F8/SF6 tamponade (6 months) 81% for PPV (p=0.2) 89.7% for PPV +SB combined 54.4% in PPV and 48.2% in PPV/SB≥20/ 40 (p 0.21) Major Review Stamenkovic ´ et al. (2014)14, Uncomplicated RD SB 68 eyes (6 months) 76.5% From 1.89±1.04 to 0.98±0.70 LogMAR (p 0.04) From 2.56±0.67 to 1.31±0.74 LogMAR (p 0.001) Better anatomical outcomes in the PPV group. PPV 30 eyes (6 months) 100% (<0.05) Both groups showed significant visual improvement 13 Continued

  5. 14 Major Review Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | Table 2: Continued Study Type of surgery No. of eyes (follow-up) SSSR (p*) Visual outcome (p*) Complications (p*) Comments Park et al. (2015)15, Phakic uncomplicated RD, age >35 years SB 72 eyes (6.9 months) 77.8% 1.38±0.87 to 0.51 ±0.48 1.84±0.97 preoperatively to 0.30 ±0.23 postoperatively Sustained submacular fluid in 38.6% Final BCVA worse in the SB group (p 0.01) Primary success rate better in PPV. Final success rate 100% in both groups PPV 57 eyes (6 months) 94.7% (p=0.01) Sustained submacular fluid in 2.8% eyes (p <0.001) 63.3% ≥ 2 line increase in BCVA Cankurtaran et al. (2017)16, Pseudophakic RDs SB 30 eyes (34 months) 73.3% No difference between groups in primary or final anatomical or visual outcomes 69.2% ≥ 2 line increase in BCVA PPV 39 PPV+silicone pseudophakic RDs (32.6 months) 32 PPV+C3F8 pseudophakic (33.7 months) RDs 77% 87.5% ≥ 2 line increase in BCVA (p 0.4) 81.2% (p 0.76) *p-value for difference in parameter in the PPV versus SB group. Abbreviations: SSSR: single-surgery success rate; SB: scleral buckle; PPV: pars plana vitrectomy; RD: retinal detachment; PVR: proliferative vitreoretinopathy; ERM: epiretinal membrane; BCVA: best-corrected visual acuity; IOP: intraocular pressure.

  6. Table 3: Study SB versus PPV: prospective studies Type of surgery No. of eyes (follow-up) SSSR (p*) Visual outcome (p*) Complications (p*) Comments Ahmadieh et al. (2005)17, (pseudophakic and aphakic RDs) SB 126 (6 months) 68.2% 0.96±0.68 Mean LogMar at 6 months Macular pucker (22%) CME (6.3%) IOP rise early postoperative period (24.6%) EOM dysfunction 4% Macular pucker (22.2%) CME (6.1%) IOP rise early postoperative period (26.3%) Baseline features matched. 20G PPV, 20% SF6 tamponade in the PPV group Trauma, glaucoma, uveitis, AMD, DR, macular hole, GRT, PVR worse that grade B excluded No significant difference in anatomical and visual outcomes and complication rates Final attachment rate 85% in the SB group and 92% in the PPV group PPV 99 (6 months) 62.6% 0.96±0.62 Mean LogMar at 6 months Sharma et al. (2005)18, Pseudophakic primary rhegmatogenous RDs SB 25 eyes (6 months) 76% 0.19±0.15 decimal acuity Intraoperative Needle perforation 4% Retinal haemorrhage 8% Early Raised IOP 4% Choroidal detachment 8% Late ERM 16% CME 4% Buckle infection 4% Diplopia 4% PVR causing failure 20% Intraoperative Iatrogenic breaks24% Retinal haemorrhage 4% Early Raised IOP 32% Late ERM 12% CME 4% PVR causing failure 4% Final anatomical reattachment 100% in both groups. Better long-term visual and anatomical outcomes in PPV in pseuophakic RDs Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | PPV 25 eyes (6 months) 84% (p 0.48) 0.28±0.12 (p 0.03) Decimal acuity Major Review Brazitikos et al. (2005)19, RCT SB 75 eyes (1 year) 83% 0.4 LogMAR Mean change in axial length at 1 year 0.95 mm Mean operating time 65.8 min (p=0.004) PPV has less operative time, more accurate diagnosis of breaks and higher single-surgery reattachment rate with less postoperative axial length changes. Continued 15

  7. 16 Major Review Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | Table 3: Continued Study Type of surgery No. of eyes (follow-up) SSSR (p*) Visual outcome (p*) Complications (p*) Comments Primary pseudophakic RRD, PVR ≤grade B Undiagnosed breaks after surgery 7 New intraoperatively diagnosed breaks 8 Mean change in axial length at 1 year 0.33 mm (p=0.0001) Lower mean operating time 54.6 min (p=0.004) Undiagnosed breaks after surgery 0 (p=0.01) New intraoperatively diagnosed breaks 22 (p=0.004) But similar final attachment rate with multiple surgeries: 96% in the SB group and 98.6% in the PPV group (p=0.37) PPV 75 eyes primary pseudophakic RRD, PVR ≤grade B 20% SF6 for endotamponade (1 year) 94% (p=0.03) 0.33 LogMAR (p=0.26) Azad et al. (2007)20, Phakic eyes uncomplicated RD SB 31 eyes (6 months) 80.6% From 1.48 (median) to 0.6 LogMAR From 1.78 (median) to 0.6 LogMAR SB and PPV comparable in outcomes PPV 30 eyes (6 months) 80% Cataract in 5 (17%) Heimann et al. (2007)21, ‘SPR study’, RCT Phakic eyes SB 209 eyes (12 months) 63.6% 0.33 Cataract progression 45.8% PVR grade B or C 12.4% Final anatomical success 96.7% and 96.6% in SB and PPV groups, respectively. PPV 207 eyes SF6 in primary Sx (12 months) 63.8% (0.97) 0.48 (0.005) Cataract progression 77.3% (<0.0005) PVR B or C 16.4% (0.08) Silicone oil used in revision surgeries in 9.1% in the SB group and 17.9% in the PPV group Benefit of SB with respect to BCVA improvement in phakic eyes Final anatomical success 93.2% and 95.5% in SB and PPV groups, respectively (comparable). Silicone oil used in revision surgeries in 21.8% in the SB group and 11.3% in the PPV group Better anatomical outcomes of PPV group in pseudophakic/aphakic groups Pseudophakic eyes SB 133 eyes (12 months) 53.4% 0.46 PVR 22.6% PPV 132 eyes SF6 in primary Sx (12 months) 72% (0.002) 0.38 (0.1) PVR 15.2% (0.1) *P-value for difference in parameter in the PPV versus SB group. Abbreviations: SSSR: single-surgery success rate; SB: scleral buckle; PPV: pars plana vitrectomy; RD: retinal detachment; PVR: proliferative vitreoretinopathy; ERM: epiretinal membrane; RCT: randomized control trial; IOP: intraocular pressure.

  8. Table 4: Study SB versus PPV: meta-analysis studies Type of surgery No. of eyes (follow-up) SSSR (p*) Visual outcome (p*) Complications (p*) Comments Arya et al. (2006)14, Uncomplicated pseuophakic RDs ‘Meta-analysis’ SB 1579 Lower initial reattachment rates OR 1.69 [95% CI 1.07– 2.68] Lower probability of final visual improvement compared with PPV/PPV+SB Higher probability of visual improvement than SB [OR 2.34; 95% CI, 1.58–3.46] Initial and final anatomical outcomes better with PPV/PPV+SB compared with SB. Final visual success highest with PPV+SB, followed by PPV alone, compared with SB Undetected breaks, loss of capsular support and macular detachment found to be significant negative predictors of primary success rate. PPV 457 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | Sun et al. (2012)22, Phakic SB 76% 88.6% final visual success PVR 10.3% Postoperative cataract 40% PVR 15% (0.1) Postoperative cataract 69.6% (0.00001) PVR 21.2% Final anatomical success 97.3% both groups. SB is superior in terms of final VA and occurrence of postoperative cataract in uncomplicated phakic RRDs. Meta-analysis of RCTs PPV 76.9% (0.8) 79.6% final visual success (0.005) Pseudophakic SB 68.8% 86.7% final visual success Final anatomical success 91.1% in the SB group versus 95.5% in the PPV group (p 0.04) PPV is more likely to achieve a favourable final reattachment in pseudophakic/aphakic RRDs. PPV 78.2% (0.16) 90.5% final visual success (0.19) PVR 17.8% (0.4) *P-value for difference in parameter in the PPV versus SB group. Abbreviations: SSSR: single-surgery success rate; SB: scleral buckle; PPV: pars plana vitrectomy; RD: retinal detachment; PVR: proliferative vitreoretinopathy; ERM: epiretinal membrane; RRD: rhegmatogenous retinal detachment. Major Review 17

  9. Major Review by Arya et al.5(table 4). Final visual success was highest when PPV was combined with SB, fol- lowed by PPV alone, Undetected breaks, loss of capsular support and macular detachment found to be significant nega- tive predictors of primary success rate in these psedophakic RDs. Even in eyes with mild vitreous haemorrhage (where peripheral fundus can be adequately visua- lized), Erakgun et al.found that though the initial visual outcome was better in the PPV group, the final visual and anatomical outcomes (at 6 months) were comparable in both groups. Various retrospective studies have also com- pared PPV alone and PPV with additional SB. Anatomical and functional success rates were better with the use of a scleral explant during PPV for uncomplicated forms of phakic rhegmato- genous RDs with inferior breaks.,6.However, they seem to have similar efficacy in the repair of a matched group of patients with primary non- complex pseudophakic RD.7 Common complications in SB according to most studies were subretinal haemorrhage due to perforation, epiretinal membrane formation and delayed absorption of submacular fluid (in non- drainage procedures). In the PPV group, the inci- dence of cataract progression and lens damage, occurrence of iatrogenic breaks was significantly more common when compared with the SB procedure. Retrospective studies suffer from the fact there may be severe selection bias as the decision to opt for a particular surgery is influenced by various other factors like preoperative findings, patient characteristics, available tools for surgery, and experience, ability and preference of the operating surgeon. have attributed the lower anatomical success in the SB group to missed small breaks possibly due to poor visualization of periphery. SB has also been shown to be associated with a significant increase in axial length postoperatively compared with PPV.16 compared with SB. The SPR study The Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment Study (SPR Study)21was the first large-scale, open-label pro- spective randomized multicentre clinical which compared SB surgery and primary PPV in rhegmatogenousretinal detachments of medium complexity with 1-year follow-up. It separated phakic and pseudophakic patients (parallel group design). Forty-five surgeons (who had to have per- formed atleast 100 SB procedures and 100 PPVs as primary surgeons) from 25 centres in five European countries recruited 416 phakic and 265 pseudophakic patients. In the phakic arm, the mean BCVA change was significantly (p=0.0005) greater in the SB group (SB, −0.71 logMAR, standard deviation [SD] logMAR, SD 0.76). In the pseudophakic arm, changes in BCVA showed a non-significant differ- ence of 0.09 logMAR. In phakic patients, cataract progression was greater (p<0.00005). In the pseudophakic group, the primary anatomical success rate (SB, 71/133 [53.4%]; PPV, 95/132 [72.0%]) was significantly better (p=0.0020), and the mean number of retina-affecting secondary surgeries (SB, 0.77, SD 1.08; PPV, 0.43, SD 0.85) was lower (p=0.0032) in the PPV group. Re-detachment rates were 26.3% (SB, 55/209) and 25.1% (PPV, 52/207) in the phakic trial and 39.8% (SB, 53/133) and 20.4% (PPV, 27/132) in the pseudophakic trial. The study showed a benefit of SB in phakic eyes with respect to BCVA improvement. No difference in BCVA was demonstrated in the pseudophakic trial; based on a better anatomical outcome, PPV was recom- mended in these patients. trial −0.56 0.68; PPV, in the PPV group Prospective studies There are relatively limited number of prospective studies that compare outcomes of SB and PPV (Table 3). In phakic eyes, most prospective studies have found better visual outcomes with SB when com- pared with PPV for uncomplicated RDs, although the final anatomical outcomes may be similar in both groups.20,21This can be explained by the higher incidence of cataract progression and diffi- culty in adequate vitreous base excision during vitrectomy. In pseudophakic eyes on the other hand, PPV is more likely to achieve a favourable anatomical outcome, though there was not much difference in final visual outcomes.17-19,21The main issue in pseudophakic/aphakic eyes is the difficulty in pre- operative visualization as the breaks are usually small and multiple, anterior and posterior capsular haze, cortical remnants, suboptimal dilatation and optical aberrations due to the IOL. Most studies Meta-analysis Table 4 summarizes the results of two large meta-analyses of studies comparing SB with PPV. The results of different studies cannot be com- pared together as the surgical techniques may be different, for example combining cataract surgery with vitrectomy in phakic patients might improve the visual acuity results, use of additional SB/ encirclage, use of 360° endolaser and the use of gas or oil for tamponade in vitrectomy may change the rate of re-detachment and anatomical progno- sis. The decision to drain or not in SB may also affect the complication rates and final outcomes. It is also important to note that most prospect- ive and retrospective studies comparing PPV with SB have employed gas as primary tamponade 18 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 |

  10. Major Review (SF6/C3F8) for PPV. Silicone oil was used only in cases of recurrent detachments. In clinical prac- tice, it is not uncommon to use silicone oil as the primary tamponading agent during PPV for rheg- matogenous RDs. Silicone oil and its associated complications can also have an impact on final visual and anatomical outcomes of PPV. Furthermore, most of these studies have used traditional 20G systems for PPV. In the current scenario, small gauge vitrectomy and microinci- sion vitrectomy systems (MIVS) have become the norm, with improved outcomes and reduced com- plication profiles which should be taken into con- sideration during these comparisons. buckle for primary repair of pseudophakic retinal detachment. Ophthalmology 2006;113:2033–40. 8. Oshima Y, Yamanishi S, Sawa M, et al. Two-year follow-up study comparing primary vitrectomy with scleral buckling for macula-off rhegmatogenous retinal detachment. Jpn J Ophthalmol. 2000;44(5):538–49. 9. Miki D, Hida T, Hotta K, et al. Comparison of scleral buckling and vitrectomy for retinal detachment resulting from flap tears in superior quadrants. Jpn J Ophthalmol. 2001;45(2):187–91. 10. Huang C, Fu T, Zhang T, et al. Scleral buckling versus vitrectomy for macula-off rhegmatogenous retinal detachment as accessed with spectral-domain optical coherence tomography: a retrospective observational case series. BMC Ophthalmol. 2013;13:12 doi: . 11. Kobashi H, Takano M, Yanagita T, et al. Scleral buckling and pars plana vitrectomy for rhegmatogenous retinal detachment: an analysis of 542 eyes. Curr Eye Res. 2014; 39(2):204–11. 12. Erakgun Tansu, et al. Scleral buckling versus primary vitrectomy in the management of retinal detachment associated with mild vitreous hemorrhage. Turk Oftalmoloji Dergisi. 2014;44(2):92–7. 6p 13. Rush R, Simunovic MP, Sheth S, et al. 23-Gauge pars plana vitrectomy versus scleral buckling versus combined pars plana vitrectomy-scleral buckling for medium-complexity retinal detachment repair. Asia Pac J Ophthalmol. 2014;3 (4):215–9. 14. Stamenkovic ´ M, Stefanovic ´ I, Senc ´anic ´ I, et al. Morphological and functional outcome of scleral buckling surgery compared to primary vitrectomy in patients with retinal detachment. Vojnosanit Pregl. 2014;71(10):920–4. 15. Park SW, Kwon HJ, Kim HY, et al. Comparison of scleral buckling and vitrectomy using wide angle viewing system for rhegmatogenous retinal detachment in patients older than 35 years. BMC Ophthalmol. 2015;15:121. 16. Cankurtaran V, Citirik M, Simsek M, et al. Anatomical and functional outcomes of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Bosn J Basic Med Sci. 2017;17(1):74–80. 17. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment: six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005;112(8):1421–9. 18. Sharma YR, Karunanithi S, Azad RV, et al. Functional and anatomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand. 2005;83(3):293–7. 19. Brazitikos PD, Androudi S, Christen WG, et al. Primary pars plana vitrectomy versus scleral buckle surgery for the treatment of pseudophakic retinal detachment: a randomized clinical trial. Retina 2005;25(8):957–64. 20. Azad RV, Chanana B, Sharma YR, et al. Primary vitrectomy versus conventional retinal detachment surgery in phakic rhegmatogenous retinal detachment. Acta Ophthalmol Scand. 2007;85(5):540–5. 21. Heimann H, Bartz-Schmidt KU, Bornfeld N, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. Ophthalmology 2007;114:2142–54. 22. Sun Q, Sun T, Xu Y, et al. Primary vitrectomy versus scleral buckling for the treatment of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled clinical trials. Curr Eye Res. 2012;37(6):492–9. Conclusions The controversy still continues and debate can go on regarding the efficacy of both these surgical procedures as a primary form of repair for RD. Many retrospective and prospective studies have shown nearly equal SSRs, anatomical success rates and functional outcomes in SB as well as PPV. In general, SB remains the method of choice in uncomplicated retinal situations, i.e., single breaks and/or a limited RD. In contrast, PPV is indicated in complicated situations. However, the decision to choose one particular type of surgery has to be individualized to that particular case scenario. It would also depend on the surgeon’s preference and comfort with a particular tech- nique. SB, although an old technique still holds good and can give excellent results if performed well. It would be advisable for the young retina surgeons to acquire this skill set. References 1. Schwartz SG, Mieler WF. Management of primary rhegmatogenous retinal detachment. Comp Ophthalmol Update 2004; 5:285–94. 2. Nam KY, Kim WJ, Jo YJ, et al. Scleral buckling technique using a 25-gauge chandelier endoilluminator. Retina 2013;33 (4):880–2. 3. SPR Study Group. View 2: the case for primary vitrectomy. Br J Ophthalmol. 2003;87:784 –7; McLeod D. Is it time to call time on the scleral buckle? Br J Ophthalmol. 2004;88:1357–9. 4. Feltgen N, Weiss C, Wolf S, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (SPR Study): recruitment list evaluation. Study report no. 2. Graefes Arch Clin Exp Ophthalmol. 2007;245:803–9. 5. Arya AV, Emerson JW, Engelbert M, et al. Surgical management of pseudophakic retinal detachments: a meta-analysis. Ophthalmology 2006;113(10):1724–33. 6. Chanana B, Azad R. Pars plana vitrectomy versus combined scleral buckling—pars plana vitrectomy for phakic rhegmatogenous retinal detachment with inferior breaks. Open J Ophthalmol. 2016;6:129–35. 7. Weichel ED, Martidis A, Fineman MS, et al. Pars plana vitrectomy versus combined pars plana vitrectomy–scleral How to cite this article Maitray A., Jaya Prakash V. and Ratra D. Scleral buckling versus vitrectomy for primary rhegmatogenous retinal detachment, Sci J Med & Vis Res Foun 2017;XXXV:10–19. 19 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 |