Pars plana vitrectomy makes paradigm shift for retinal surgery in Europe

Take-home message: European retinal surgeons have been shifting to the use of pars plana vitrectomy for the repair of rhegmatogenous retinal detachment, but scleral buckle surgery remains a viable choice in young and uncomplicated cases.

By Cheryl Guttman Krader; Reviewed by Christiane I. Falkner-Radler, MD

Vienna, Austria-European retina specialists are increasingly choosing primary vitrectomy for repair of rhegmatogenous retinal detachment (RRD) and using microincisional techniques (23 and 25 gauge).

However, scleral buckle is still the main procedure in uncomplicated cases, and particularly for younger, phakic patients in whom the vitreous may still be attached, said Christiane I. Falkner-Radler, MD.

“Vitrectomy is clearly the primary procedure for repair of complicated detachments in which there is proliferative vitreoretinopathy, giant tears, and macular holes,” said Dr. Falkner-Radler, associate professor of ophthalmology, Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery, Rudolf Foundation Clinic, Vienna.

The anatomic success rates are excellent in pseudophakic cases, and available evidence supports phacovitrectomy as a good option in phakic eyes, Dr. Falkner-Radler said.

Identifying cases for RRDs

The types of cases where scleral buckle may be chosen are not that common, and so the majority of RRDs are being treated with pars plana vitrectomy alone or with phacoemulsification in phakic eyes, she noted.

“Results from published studies show that adding a scleral buckle to vitrectomy does not improve the surgical outcome and that for uncomplicated detachments, scleral buckle has a higher anatomic success rate than pneumatic retinopexy,” Dr. Falkner-Radler said. “That information may explain why pneumatic retinopexy never gained much popularity in Europe.”

Dr. Falkner-Radler reviewed European studies evaluating outcomes of RRD surgery that were published over the past decade. The multicenter SPR study compared scleral buckle with pars plana vitrectomy (PPV) to manage medium complexity RRD. Representing one of the largest studies conducted in Europe, it randomly assigned 681 eyes after stratifying them into phakic and pseudophakic cohorts.

Among phakic eyes, both procedures had a single operation success rate (SOSR) of about 64%, but the functional outcome was better after scleral buckle surgery.

In the pseudophakic subgroup, vitrectomy had a higher anatomic success rate than scleral buckle (72% versus 53%), vision outcomes were similar for the two procedures, and the best results were seen when vitrectomy was combined with scleral buckle.

However, a large randomized clinical trial including 1000 eyes found no benefit from adding a scleral buckle to vitrectomy.

PPV data

In addition, data from the United Kingdom National Ophthalmology Database Study of Vitreoretinal Surgery that included 3,403 eyes showed the re-treatment rate was higher in eyes that had PPV plus a scleral buckle compared with those having PPV or scleral buckle surgery alone, 14.5% versus 13.3% and 12.3%, respectively.

Dr. Falkner-Radler and colleagues compared PPV with laser with PPV with scleral buckle and found similarly high anatomic success rate of 93% in the two groups.

However, there was less refractive error change when PPV was performed with laser than with a scleral buckle (–0.20 versus –0.88 D).

A study from Greece that randomized 150 pseudophakic eyes similarly showed a higher SOSR after PPV compared with scleral buckle (94% vs. 83%) with no difference in vision between the two surgical groups.

Results of the European Vitreoretinal Society Retinal Detachment Study support scleral buckle as a good option for phakic patients and vitrectomy resulted in better outcomes than scleral buckle surgery for more complex cases. Among pseudophakic patients, vitrectomy alone was associated with a better outcome than vitrectomy with a scleral buckle.

In a two-center study involving Dr. Falkner-Radler’s institution and Weill Cornell Medical College in New York, scleral buckle was the predominant procedure performed in the European cohort (66%) and PPV was the leading method chosen for repair by the American surgeons (83%). Overall, however, the SOSR was about the same at the two institutions, 89% and 85%.

“The cases in that study were performed in 2007 and 2008, and over time, the proportion of primary vitrectomy cases has increased at our institution,” Dr. Falkner-Radler said. “In 2012, 75% of retinal detachment repairs were performed with PPV.”

Cataract considerations

A study from Spain and Portugal comparing outcomes of PPV in pseudophakic and phakic eyes showed no difference in the SOSR between groups, but better vision in the pseudophakic eyes due to cataract formation in the phakic cohort.

Two recently published studies evaluating phacovitrectomy in phakic eyes showed excellent anatomic outcomes (SOSR 88%). The refractive results were also good as the procedure induced a myopic shift of only about 0.34 D.

Final thoughts

As use of PPV for RRD repair grows, surgeons should be aware there is a learning curve.

In a French study investigating outcomes of PPV, the primary retinal reattachment rate was about 81% for experienced surgeons and 70% for less experienced surgeons.

Christiane I. Falkner-Radler, MD

E: Christiane.falkner@chello.at

This article was adapted from Dr. Falkner-Radler’s presentation during the 2014 meeting of the American Academy of Ophthalmology. Dr. Falkner-Radler has no relevant financial interests to disclose.