|Year : 2020 | Volume
| Issue : 3 | Page : 91-94
Success rate of vitrectomy in rhegmatogenous retinal detachment with choroidal detachment with perioperative oral steroids after the complete settlement of choroidal detachment: Our experience
Shilpi Harshal Narnaware1, Prashant Keshao Bawankule1, Dhananjay Raje2, Moumita Chokraborty2
1 Department of Vitreo Retina, Sarakshi Netralaya, Nagpur, Maharashtra, India
2 Department of Biostats MDS Bio-Analytics Pvt. Ltd., Nagpur, Maharashtra, India
|Date of Submission||07-Feb-2019|
|Date of Decision||03-Feb-2020|
|Date of Acceptance||03-Feb-2020|
|Date of Web Publication||4-Dec-2020|
Shilpi Harshal Narnaware
Sarakshi Netralaya, Plot No. 19, Rajiv Nagar, Wardha Road, Nagpur - 440 025, Maharashtra
Source of Support: None, Conflict of Interest: None
Purpose: The purpose of this study is to study the anatomic and functional success of pars plana vitrectomy (PPV) in rhegmatogenous retinal detachments (RRD) with choroidal detachment (CD) after the complete settlement of CD following oral steroids. Materials and Methods: A prospective, observational, case series was conducted on 30 eyes of 30 patients with RRD with CD during January 2014–October 2017. Oral steroids (tablet omnacortil in dose of 1 mg/kg) were started before surgery, and the patient underwent PPV after choroidals was settled (approximately 5–7 days after starting oral steroids). Primary and final anatomical success rates and functional success rates were obtained. The exclusion criteria included previous retinal detachments surgery, combined RRD, and traumatic RRD. Results: Primary success was 53.3% (16/30) Final success was observed in 80% cases. Sixty percent of patients achieved best-corrected visual acuity of >20/200. Conclusion: The perioperative use of oral steroids help in increasing the success rate by reducing hypotony and reducing inflammatory component.
Keywords: Choroidal detachment, oral steroids, rhegmatogenous retinal detachment
|How to cite this article:|
Narnaware SH, Bawankule PK, Raje D, Chokraborty M. Success rate of vitrectomy in rhegmatogenous retinal detachment with choroidal detachment with perioperative oral steroids after the complete settlement of choroidal detachment: Our experience. J Clin Ophthalmol Res 2020;8:91-4
|How to cite this URL:|
Narnaware SH, Bawankule PK, Raje D, Chokraborty M. Success rate of vitrectomy in rhegmatogenous retinal detachment with choroidal detachment with perioperative oral steroids after the complete settlement of choroidal detachment: Our experience. J Clin Ophthalmol Res [serial online] 2020 [cited 2021 Feb 25];8:91-4. Available from: https://www.jcor.in/text.asp?2020/8/3/91/302200
The reported incidence of rhegmatogenous retinal detachments (RRD) with associated choroidal detachment (CD) varies between 2.0% and 4.5%.,, RRD with CD is a rare condition which is usually associated with hypotony, anterior and posterior uveitis, and more chances of proliferative vitreoretinopathy (PVR), which is attributed to increased inflammatory mediators. Other causes for more chances of the development of CD include high myopia, aphakia, pseudophakia, advanced age, and macular hole. Uveitis may lead to hypotony which can cause vasodilataion and extravasation in choroid, leading to choroidal and ciliary body detachment causing further reduction in aqueous production.,,, CD is a preoperative risk factor for the failure of surgeries in this subset of RRD. This form of detachment progresses rapidly with poor surgical success rate and hence poor visual prognosis. The use of perioperative pharmacological management in the form of steroids has definitely improved the surgical rate in such patients. While other studies have shown the effect of various routes of steroids administration for settlement of choroidals., Various studies have reported the success rate ranging from 35.0% to 62.0% by using buckle,,, while with pars plana vitrectomy (PPV), the success rate reported to be as high as 77%.,, Few studies have shown improved anatomical surgical outcomes in combining PPV with scleral buckle,, while others did not reported much change in success rates if two procedures are combined.
| Materials and Methods|| |
A prospective case series of 30 patients of RRD with CD done at vitreoretinal center in India. CD was diagnosed preoperatively with indirect ophthalmoscopy and B-scan. PVR stage was graded as defined by the recent classification methods of the Retina Society Terminology Committee (1991). Patients’ demographics, including gender and age, were recorded. All patients received detailed ophthalmic examinations, including best-corrected visual acuity, intraocular pressure (IOP) with applanation tonometry, anterior segment evaluation with a slit-lamp microscope, fundus examination with a binocular indirect ophthalmoscope, and B-scan ultrasound (NIDEK B-scan machine) performed by experienced retinologists. The exclusion criteria were patients with a history of trauma, combined detachments, history of any previous retinal surgery, and patients with incomplete follow-up period. All cases received course of oral steroids and taken for vitrectomy after complete settlement of choroidals which was confirmed on indirect ophthalmoscopy and B-scan. Intraoperatively, the number of the retinal breaks and area of exposed choroid was noted. The area of exposed choroid (at the end of surgery) were grouped into two categories: ≤5 disc diameter (DD) and >5 DD [Figure 1].
This study was approved by the hospital’s ethics committee.
All cases received oral steroids (tablet omnacortil 1 mg/kg body weight) and were taken for surgery only after choroidals settled completely (after 5–7 days). After receiving informed consent, surgery was performed under local anesthesia. In all cases, 23 G PPV with Alcon constellation was performed using a noncontact wide-angle viewing system (oculus BIOM). Trocars were placed and confirmed to be in vitreous cavity before infusion cannula is switched on. Core vitrectomy was followed by PVD induction. Membranes were peeled. Base excision was done in all cases. No cases received encircling/sclera buckle. Perfluorocarbon liquids (PFCL) were used to flatten the retina, and then PFCL-air exchange was done. Endolaser photocoagulation using curved probe was applied around the retinal tear and 360° to the vitreous base. All patients received silicone oil (1000 centistokes) tamponade at the end of the surgery. Perioperatively, all patients continued receiving oral steroids in tapering doses. Patients were examined postoperatively and followed for at least 12 months after the last surgery. Silicon oil removal was done 8–10 weeks later in attached retina, while earlier in recurrent retinal detachments (RD) under oil. Patients were examined postoperatively at 6 weeks, 3 months, 6 months, and 12 months after the last surgery. Patients were considered “lost to follow-up or incomplete follow-up” if they did not turn up till 6 months after surgery.
Treatment success was defined in terms of primary and final anatomical success rates and functional success rate. Primary success (PS) was defined as the probability of nonoccurrence of RD 3 months after silicone oil removal. RRD under oil was considered primary failure. Thus, if n1 is the initial number of patients and r1 is the number of patients without recurrence of RD, then the PS rate was defined as r1/n1. If n2 is the number of patients undergoing second surgery due to recurrence of RD and r2 is the number of success after second surgery, then the FS rate was defined as:
where n2 = n1 − r1 − c1. Here, c1 is the number of censored cases after the first surgery.
Patients who had recurrent detachment within 3 months of the first surgery were classified into primary failure while patients who had detachment 3 months after silicone oil removal were classified as a secondary failure. Censored cases were defined as patients who were lost to follow-up after 6 months of the first surgery and were not included in calculating the PS. In other words, the FS rate is defined as the nonoccurrence of RD at 3 months after the last retinal reattachment procedures.
| Results|| |
[Table 1] gives the descriptive statistics of patient characteristics with choroidals. There were 30 (3.6%) patients with choroidals in the study sample. The mean age of these patients was 60.2 ±16.69 years. Further, out of 30 patients, there were 26 (86.7%) males, while only 4 (13.3%) females. Bare choroid area of ≤ 5 µm2 was observed in 20 (66.6%) patients with choroidals, while 10 (33.3%) had area > 5 µm2. Further, there were 16 (53.3%) patients with PVR < C, while 14 (46.7%) had PVR > C.
[Table 2] provides the distribution of patients according to choroidals. Out of 30 cases with choroidals, 16 (53.3%) cases had primary success, while 12 cases had failures ( 8 Primary failures, 4 secondary failures). Out of these, 8 (66.7%) had secondary success. Thus, the final success was observed in 24 (80%) cases.
|Table 2: Primary and final success rates in patients with retinal detachments with choroidals|
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[Table 3] provides the visual ( functional ) success rate. 60% patients achieved vision of >/= 20/200 while rest had post op visual gain less than 20/200.
|Table 3: Functional success rate in patients with retinal detachment with choroidals|
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[Table 4] provides the anatomical success rate according to bare choroid area. Primary success was obtained in 14 ( 70.0% ) cases in bare choroid area </= 5 DD while in 2 ( 20.0% ) cases when area > 5 DD. Final success rate was 90.0% & 60.0 % respectively. The p value for the [Table 4] is 0.1288 using Fishers exact test indicating insignificant association between exposed choroid area & the success.
| Discussion|| |
RRD with CD is a special type of subset of RRD with rapid progression and higher failure rate, resulting in poor anatomical and visual success. In contrast to patients with RRD, intravitreous inflammatory mediators are upregulated in patients with RRDCD, who usually experience more severe PVR. Recently PPV is advocated as a primary modality of treatment in such cases with improved success rates, as all retinal breaks can be identified and also complete excision of proliferative and concentrated vitreous is possible with PPV.,, However, doing PPV in hypotonous eyes with CD is technically difficult. This problem and resulting increase in success rate is advocated with the use of oral steroids preoperatively. An increase in success rate from 66.7% to 81.8% was noted in patients who received oral steroids. While few others favor the use of periocular or intra-vitreal steroids to avoid systemic side effects of oral steroids., Recurrence is primarily due to PVR and use of silicone oil tamponading was proposed in complicated RRD with PVR., Loo et al. have proposed the use of silicone oil tamponading to overcome the problem of postoperative hypotony in cases of RRD with CD. The anatomical success rate in our study increased from 53.3% to 80%, with final functional success rate of 60%. Bare choroid (because of breaks/retinotomies) disposes to more PVR in the postoperative period and increases the risk of recurrence. Regarding bare choroid area, the primary anatomical success rate is higher when bare choroid area is <5 DD, though the difference was not statistically significant. XU et al. achieved the overall success of 58% in their study.
CD usually occurs after the development of RRD. Studies have shown frequent association of CD with RRD in patients with high myopia, aphakia, pseudophakia, and advanced age who present with low IOP and multiple retinal breaks., A study has shown correlation of macular hole with the development of CD in RRD.
Although the pathogenic mechanism of CD following RRD is not well established, hypotony is considered a main cause which may stimulate choroidal abnormalities, including dilatation and hyperpermiability of choroidal vessels leading to CD. In addition, edema of the ciliary body further reduces the generation of aqueous humor and causes prominent hypotony, deteriorating the dilatation and hyperpermeability of choroidal vessels and leading to progression of CD. Therefore, a positive feedback loop is established. The use of perioperative oral steroids helps in reducing this hypotony which is associated with CD in RRD cases, thereby increasing the anatomical and functional success rates.
| Conclusion|| |
RRD with CD need to be treated with systemic steroids for the resolution of choroidals before surgery. Vitrectomy after subsidence shows higher success rate than patients taken for surgery with choroidals.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Gottlieb F. Combined choroidal and retinal detachment. Arch Ophthalmol 1972;88:481-6.
Seelenfreund MH, Kraushar MF, Schepens CL, Freilich DB. Choroidal detachment associated with primary retinal detachment. Arch Ophthalmol 1974;91:254-8.
Sharma T, Challa JK, Ravishankar KV, Murugesan R. Scleral buckling for retinal detachment. Predictors for anatomic failure. Retina 1994;14:338-43.
Jarrett WH 2nd
. Rhematogenous retinal detachment complicated by severe intraocular inflammation, hypotony, and choroidal detachment. Trans Am Ophthalmol Soc 1981;79:664-83.
Dai Y, Wu Z, Sheng H, Zhang Z, Yu M, Zhang Q. Identification of inflammatory mediators in patients with rhegmatogenous retinal detachment associated with choroidal detachment. Mol Vis 2015;21:417-27.
Yang CM. Pars plana vitrectomy in the treatment of combined rhegmatogenous retinal detachment and choroidal detachment in aphakic or pseudophakic patients. Ophthalmic Surg Lasers 1997;28:288-93.
Sharma T, Gopal L, Badrinath SS. Primary vitrectomy for rhegmatogenous retinal detachment associated with choroidal detachment. Ophthalmology 1998;105:2282-5.
Loo A, Fitt AW, Ramchandani M, Kirkby GR. Pars plana vitrectomy with silicone oil in the management of combined rhegmatogenous retinal and choroidal detachment. Eye (Lond) 2001;15:612-5.
Gui JM, Jia L, Liu L, Liu JD. Vitrectomy, lensectomy and silicone oil tamponade in the management of retinal detachment associated with choroidal detachment. Int J Ophthalmol 2013;6:337-41.
Sharma T, Gopal L, Reddy RK, Kasinathan N, Shah NA, Sulochana KN, et al
. Primary vitrectomy for combined rhegmatogenous retinal detachment and choroidal detachment with or without oral corticosteroids: A pilot study. Retina 2005;25:152-7.
Shen L, Mao J, Sun S, Dong Y, Chen Y, Cheng L. Perioperative pharmacological management of choroidal detachment associated with rhegmatogenous retinal detachment. Acta Ophthalmol 2016;94:391-6.
Wei Y, Wang N, Chen F, Wang H, Bi C, Zu Z, et al
. Vitrectomy combined with periocular/intravitreal injection of steroids for rhegmatogenous retinal detachment associated with choroidal detachment. Retina 2014;34:136-41.
Burton TC. Preoperative factors influencing anatomic success rates following retinal detachment surgery. Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol 1977;83:OP499-505.
Schoenberger SD, Miller DM, Riemann CD. Outcomes of 23-gauge pars plana vitrectomy in combined scleral buckling and vitrectomy for complex rhegmatogenous retinal detachments. Eye Rep 2011;1:5-9.
Ghoraba HH. Primary vitrectomy for the management of rhegmatogenous retinal detachment associated with choroidal detachment. Graefes Arch Clin Exp Ophthalmol 2001;239:733-6.
Rahman N, Harris GS. Choroidal detachment associated with retinal detachment as a presenting finding. Can J Ophthalmol 1992;27:245-8.
Adelman RA, Parnes AJ, Sipperley JO, Ducournau D; European Vitreo-Retinal Society (EVRS) Retinal Detachment Study Group. Strategy for the management of complex retinal detachments: The European vitreo-retinal society retinal detachment study report 2. Ophthalmology 2013;120:1809-13.
Duan AL, Wang JZ, Wang NL. The pilot study of intravitreal injection of triamcinolone acetonide for treatment of retinal detachment with choroidal detachment. Zhonghua Yan Ke Za Zhi 2005;41:606-9.
Bardak Y, Çekiç O, Tig US. PPV-silicone oil treatment in pseudophakic retinal detachment with proliferative vitreoretinopathy. J Retina Vitreous 2006;14:115-8.
Çakir M, Pekel G, Agca A. Use of 5000 cs silicone oil in con-junction with pars plana vitrectomy for eyes with complicated retinal detachments. J Retina Vitreous 2008;16:45-50.
Xu H, Lutrin D, Wu Z. Outcomes of 23-gauge pars plana vitrectomy combined with phacoemulsification and capsulotomy without intraocular lens implantation in rhegmatogenous retinal detachment associated with choroidal detachment. Medicine (Baltimore) 2017;96:e7869.
Kang JH, Park KA, Shin WJ, Kang SW. Macular hole as a risk factor of choroidal detachment in rhegmatogenous retinal detachment. Korean J Ophthalmol 2008;22:100-3.
Langham ME, Regan CD. Circulatory changes associated with onset of primary retinal detachment. Arch Ophthalmol 1969;81:820-9.
Brav SS. Serous choroidal detachment. Surv Ophthalmol 1961;6:395-415.
[Table 1], [Table 2], [Table 3], [Table 4]