Management of primary rhegmatogenous retinal detachment with inferior breaks

Abstract

Background: Rhegmatogenous retinal detachments (RRD) with inferior breaks are usually treated by scleral buckling (SB) or pars plana vitrectomy (PPV) or a combination of both methods. However, applying a SB during PPV may produce a risk of choroidal haemorrhage. Following a recent pilot study showing that such cases can be safely treated by PPV without SB the authors re-examined their management of RRD in which inferior breaks were present.

Methods: All patients had a detached vitreous and a complex configuration of retinal breaks. A case-control study was performed to analyse the surgical methods and results of PPV on 48 consecutive patients with RRD associated with inferior breaks and 48 age/sex matched controls who underwent PPV for RRD without inferior breaks. Exclusion criteria were giant retinal tears, retinal dialysis, trauma, proliferative vitreoretinopathy (PVR) grade B or higher, schisis detachments, and eyes that had been operated previously for RRD. A simple algorithm was followed to manage patients with inferior breaks. All patients underwent a standard three port PPV with intraocular gas tamponade without supplementary SB. Patients were asked to posture face up or right or left side down for 1 week.

Results: 39 of the 48 patients (81.3%) with inferior breaks were treated successfully with one operation. 41 of 48 patients (85.4%) control patients achieved primary success. The final success rate was 95.8% in both groups. There was no statistical difference between the two groups. When all the cases of RRD were analysed (including external plomb/non-drain procedures) the primary success rate was 89% and final success rate 97.5%.

Conclusions: This study has shown that acceptable success rates can be achieved using PPV alone to treat RRD with inferior breaks. Complications are minimised and patients in this high risk group have an 81% chance of primary success. Pars plana vitrectomy and gas will successfully reattach the retina and a supplementary SB, to support the inferior retina, is unnecessary as the intraocular gas, and face up or, right or left side down positioning will tamponade breaks satisfactorily.

Figure 1

Treatment protocol for patients with inferior breaks (PPV, pars plana vitrectomy).

Figure 2

Retinal drawings showing examples of retinal detachments with inferior breaks treated by PPV. Detached retina in dark grey, attached retina in light grey, breaks in black, and lattice are shown.

Figure 3

Success rates (% cases). Success rates are similar for the patients with inferior breaks and controls (p = 0.63). Our overall data are calculated from 279 primary RRDs undergoing PPV or SB, excluding cases with PVR, giant tears, dialyses, and retinoschisis.

Figure 4

Change in vision (logMAR VA). All points below the line of equality show an improvement in vision. No difference was observed between the inferior breaks group and controls.