Findings from the Persimmon Study for macula-off retinal detachments

Sean D. Adrean MD, FAAO, Retina Consultants of Orange County, sat down with Sheryl Stevenson, Group Editorial Director – Eye Care, to discuss the key takeaways from his presentation, "Purposeful Pneumatic Induced Resorption of Submacular Fluid in Macula-off Retinal Detachments," at the 11th Annual Vit-Buckle Society meeting, April 13 to 15, in Las Vegas, Nevada.

Video transcript

Editor’s note: This transcript has been edited for clarity.

Sheryl Stevenson: We're joined today by Dr. Sean Adrean, who is presenting at this year's Vit-Buckle Society conference. Could you tell us about your talk this year on the Persimmon Study?

Sean D. Adrean, MD: Today we'll be talking about macula-off retinal detachments, and the different ways of repairing these retinal detachments. Over the years, the anatomic results have certainly improved as well as the visual results [are] getting better. We've talked about both putting buckles on as well as treating them with vitrectomies alone. Those have all been very good ways of taking care of retinal detachments. Of course, we'd like to get better visual outcomes for our patients. A lot of times, especially when I was training, there was an emphasis on making sure that the retina itself was very flat after surgery. Ways we would go about doing that would be either doing a drainage retinotomy and removing all the fluid or, as I learned in my fellowship, we would use perfluorocarbon liquid with heavy oil and push the retina flat, and then make sure to get rid of all the fluid and then laser the retina down so that you'd have a good anatomic result.

There are other ways of dealing with retinal detachments. When I first came to practice here at Retina Consultants, one of my partners emphasized, you didn't need to make the retina completely flat at the end of surgery. You just needed to make sure that there was a good chorioretinal adhesion between the retina and the core right where the break was. Often we'd leave fluid at the back of the posterior pole and these patients did well.

We did a retrospective study and I looked at all of my macula-off retinal detachments over the last 10 to 12 years, and there's about 187 patients that had macula-off retinal detachments. I was interested in looking at specifically those that we fixed with 1 surgery that hadn't longer than 6 months of follow up as well as that were repaired with this method—no drainage retinotomy or anything like that, or perfluorocarbon liquid, and also that had a vitrectomy surgery not a scleral buckle alone.

After we excluded those patients that had some of those things we weren't interested in looking at, there's 127 patients that remained. We looked at their preoperative vision and their postoperative vision and also different aspects of the retinal detachment itself, like were they phakic or pseudophakic; did we put on a buckle or not; the age of the patients when they came into the surgery; the presenting visual outcomes; or initial vision, and as well as whether they're phakic or not. The average age of the patients was 65 years of age. There were 84 males and 43 females, and we also excluded patients that developed proliferative vitreoretinopathy just so we could get a good concept of their visual outcome. Twelve of those patients did have PVR [proliferative vitreoretinopathy] and they were excluded, leaving 127 patients.

We also looked at time that the retinal detachment was present, and most of these retinal detachments were repaired within 1 to 3 days depending. We would historically look and say, 'Well, how long has your retina been detached,' and so we looked at those results as well. The initial vision for most of the patients was around 20/400, for some groups 20/200, and some were worse 20/800. When we broke down those patients by their time between treatment for retinal detachment repair, we actually found no difference if they were repaired within 24 hours, or if they were repaired within 4 to 7 days, or even 1 to 2 weeks, or even up to 3 weeks. We did exclude patients that had retinal detachment longer than 6 weeks. We found that at 6 months, the vision for most of these patients was in the 20/40 or 20/50 range. Their best achieved vision at about 14 months on average was about 20/32 which is very good.

Also, we looked at patients and we broke it down by visual acuity. If their vision was better than 20/100, they did better than if their vision was worse than 20/100 at presentation. If their vision was better than 20/100, their best achieved vision was 20/25. If it was worse than 20/100, their best achieved vision was 20/32. About 79% of patients were able to achieve 20/40 vision or better at their best-corrected vision, which, again, was about 14 months after the initial repair with retinal detachment.

Female and male patients had roughly equivalent visions, although female patients did tend to take a little bit longer to achieve their best-corrected vision. By presenting age, if your patient was younger than 80, they had better visual outcomes than if they were older than 80. So that mean achieved best-corrected vision for patients older than 80 did average 20/50 versus the other subgroups, which was 20/32 or 20/40.

As far as postoperative complications that are roughly equivalent to what's reported in the literature, where there could be some CME [cystoid macular edema] in about 8% and ERM [epiretinal membrane] formation in about 5%, which was roughly equivalent to other reported studies.

The thought here is that these patients actually could do just as well, if not better, with this treatment modality. We've known from the literature that in the pneumatic retinopexy trials, the PIVOT Trial, those patients that were repaired with pneumatic retinopexy would tend to have improved vision over the vitrectomy-alone patients ranging in that 20/32 range versus the vitrectomy from mac-off, and that study report was about 20/40.

We also know that central serous chorioretinopathy patients with obviously a different disease process have neurosensory fluid but as that goes away, patients get excellent vision. My thought process here is that you have very close interdigitations between the photoreceptors and the retinal pigment epithelium, and by allowing the RP pump to pump the fluid out and slowly allowing the retina to reattach, they could interdigitate in a more physiologic fashion, allowing for better visual results. That's what we found in this study.