Montgomery and informed consent during Covid-19: Pneumatic retinopexy versus pars plana vitrectomy or scleral buckling for retinal detachment repair.

Recent reports suggest that the use of an outpatient-based procedure (pneumatic retinopexy, PR) for retinal detachment repair should be encouraged within the UK, especially in light of Covid-19 and possible restrictions/competing demands on access to operating theatres. It is therefore essential that patients receive comprehensive information about the risks and benefits of this approach compared with a formal surgical repair either by pars plana vitrectomy (PPV) and/or scleral buckling (SB). We report a retrospective case series of retinal detachments (RD) satisfying the strict selection criteria for PR but who were managed with formal surgery. Single-operation success rate for PPV/SB at six months follow-up was 93.8% in our study, higher than published primary success rates for PR (60-80%). When counselling patients for possible PR, the ease, speed and potentially reduced co-morbidity of an outpatient-based procedure needs to be balanced against its significantly higher failure rate in comparison with primary PPV/SB.

Reoperation for rhegmatogenous retinal detachment as quality indicator for disease management: a register study.

PURPOSE: To establish a quality indicator that could be used in optimizing treatment for rhegmatogenous retinal detachment (RRD). METHODS: The Danish National Patient Registry was used to identify surgery conducted in Denmark for RRD in the period 01 January 2001-31 December 2009. Cases were identified by diagnosis and surgical codes. RESULTS: A total of 6522 cases were operated for a primary RRD in the study period, and 22% (1434 patients) were reoperated for a redetachment. A Cox regression analysis showed that the risk of redetachment was equal to or less than detachment on the fellow eye 1 year after primary surgery with techniques not using silicone oil. The same was true 1.5 years after surgery for techniques using silicone oil. Based on this, we established a quality indicator defining failure as the need for operation for redetachment within 1 year from initial surgery when using techniques without oil and after 1.5 years for techniques using oil. Also the lack of oil removal within 1 year from initial surgery should be noted as an operational failure. We applied the quality indicators on the cohort of 6522 RRDs and found that in Denmark the need for redetachment surgery has decreased over time and also that high-volume departments have better outcome compared to smaller ones. CONCLUSIONS: The risk of reoperation for redetachment after initial surgery fulfils the criteria for a good quality indicator and can be used in RRD surgery. This indicator could aid in optimizing the management of RRD patients to minimize morbidity.

Does surgical experience have an effect on the success of retinal detachment surgery?

PURPOSE: To examine the relationship between surgeon experience and success rates in retinal detachment surgery. METHODS: Success rates during a follow-up of 11 months of 8 surgeons who performed in total 375 retinal detachment procedures ranging from 14 to 115 cases between December 1997 and January 2002 were correlated to the total number of vitreoretinal procedures ranging between 176 and 2,587. All patients received either scleral buckling or vitrectomy, and complicated cases were excluded. RESULTS: Mean primary anatomical success rates were 0.69 ± 0.14 for scleral buckling and 0.9 ± 0.05 for primary vitrectomy (P < 0.05). The primary anatomical success rates did not correlate to the number of vitreoretinal procedures. Seven of the eight surgeons showed an intraindividual learning effect with better success rates in the second versus the first half of the observed procedures. The learning effect was correlated to the total number of procedures with a higher effect in inexperienced surgeons. CONCLUSION: An intraindividual learning effect that was higher in inexperienced surgeons could be demonstrated. The learning effect was reduced by half after 500 vitreoretinal procedures while the primary anatomical success rates were not correlated to the number of vitreoretinal procedures.

Is buckle surgery still the state of the art for retinal detachments due to retinal dialysis?

PURPOSE: Retinal dialysis is a frequent cause of retinal detachment in infants and young adults. The authors report long-term results obtained with conventional detachment surgery in a large consecutive series. METHODS: Fifty-two eyes of 50 patients with retinal detachment due to dialysis underwent a segmental buckling procedure between January 1990 and December 1998. Patient characteristics and surgical results at 1 year of follow-up were evaluated. In 2007, 40 eyes from these groups were reexamined for long-term results (follow-up: 9 to 17 years; median: 13.4 years). RESULTS: The mean age of the patients was 12.8 years (range = 6 to 28 years). Preferred locations of the dialyses were inferotemporal (72%) and superonasal (16%). The macula was detached in 82%. At 1 year of follow-up, the retina was completely reattached after one surgical procedure in 87% and after two procedures in 97%. Long-term follow-up of 40 of 52 eyes revealed no retinal redetachment, but additional surgeries had been performed. Visual acuity improved in 70% of the eyes, but only 40% reattained reading vision due to the high rate of macula-off retinal detachment preoperatively. CONCLUSION: Scleral buckling for retinal detachment due to dialysis yields good results, even in the long term, and remains the treatment of choice for these usually young patients despite the increasing popularity of primary vitrectomy.

[Current treatment of simple retinal detachment. Advantages and inconveniences of permanent and temporary scleral buckling compared with gas expansion of the retina]. / Traitement actuel des décollements rétiniens simples. Avantages et inconvénients des indentations sclérales durables et des indentations éphémères, vis-à-vis de l'expansion pneumatique de la rétine.

Limited cryopexy followed by attachment to the sclera of a small, cylindrical silicone sponge at the site of the tear leads in most cases to a prompt reduction of any non-complicated rhegmatogenous detachment. As a rule, no drainage of the subretinal fluid is necessary. If an inflatable silicone balloon is used in lieu of a permanent tampon, the short-term result may be the same; renewed tension of the vitreous bands which caused the tear may lead, however, to a redetachment in the long term. Intravitreal injection of an insoluble gas (mostly perfluoro-propane or hexafluorure ) may also be used to close up the tear, while cryopexy or photocoagulation are to be applied to seal its borders. After resorption of the gas the vitreous bands will again be under tension, and the risk of a recurrence appear. The fact that the vitreous chamber must be entered entails, on the other hand, some risks of its own.

Geometric analysis of radial buckling.

Tension analysis along the retinal surface demonstrates the advantage of meridional buckles over limbal-parallel buckles. A cylindrical sponge generates tensional forces in the retina along the long axis of the buckle and perpendicular to it. The tension perpendicular to the sponge is positive, and the retina and retinal pigment epithelium stretch in that direction. The tension along the long axis is positive (stretching) when the buckle is less than 90 degrees arc length; and negative (compression), greater than 90 degrees for a 5-mm sponge. Consequently, retinal compression folds on the buckles occur for buckles of arc length greater than 90 degrees. These tension forces at right angles to each other explain the development of (1) concave retinal detachment or retinal folds off short limbal-parallel buckles, (2) retinal folds on long limbal-parallel buckles, and (3) fishmouthing of horseshoe tears overlying a limbal-parallel buckle. The buckle increases retinal surface area overlying the buckle. The significance of this is not clear, but it may explain the lessening or disappearance of compression folds on the buckle in time.