Pars plana vitrectomy for primary rhegmatogenous retinal detachment

Figures & data

Figure 1 Primary rhegmatogenous retinal detachment, left eye, with a flap retinal tear at 1:00.

Figure 2 Pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment, utilizing wide-field imaging and small-gauge transconjunctival sutureless instrumentation.

Table 1 Pars plana vitrectomy (PPV) versus scleral buckling (SB)

	PPV	SB
Visualization of retinal breaks	Generally better	Generally good
Relief of vitreoretinal traction	Direct	Indirect
Location of retinal break	More effective for superior breaks	Effective regardless of break location
Subretinal fluid drainage	Internal	External
Post-operative positioning	Generally required	Generally not required
Post-operative pain	Generally less	Generally more
Surgical costs	Higher	Lower
Advantages	Clears vitreous opacities	Supports “missed” breaks
	Giant retinal tears	Allows early air travel
	Identification of “missed” breaks
	Faster foveal re-attachment
Potential complications	New retinal breaks	Refractive change
	Elevated intraocular pressure from gas bubble	Motility disturbance
	Retinal or optic nerve trauma	Retinal or vitreous incarceration
	Induced cataract	Migration of buckling elements
	Disruption of LASIK flap	Infection of buckling elements
	Moisture condensation on silicone	Suprachoroidal or subretinal hemorrhage
	IOL during fluid-air exchange
	Retained perfluorocarbon liquids
	Retinal incarceration

Abbreviations: IOL, intraocular lens; LASIK, laser-assisted in situ keratomileusis.

Adapted from Schwartz and Flynn (2006).

Table 2 Pars plana vitrectomy: traditional teaching versus current literature

Clinical variable	Traditional teaching	Newer literature
Inferior breaks	Less effective for patients with inferior breaks	Favorable outcomes in these patients1,2,3,4
Gas tamponade	Importance of long-acting gas tamponade	Favorable outcomes with air or short-acting gas tamponade2,3,4
Prone positioning	Importance of prone positioning	Favorable outcomes in patients with inferior breaks without prone positioning4

1 Sharma et al 2004.

2 Martinez-Castillo, Verdugo, et al 2005.

3 Martinez-Castillo, Boixadera, et al 2005.

4 Martinez-Castillo et al 2007.

Table 3 Selected case series of pars plana vitrectomy for rhegmatogenous retinal detachment

Study	Number of patients	SOSR	Visual acuity outcomes	Comments
Escoffery et al 1985	29	79%	≥20/50 in 81%	Phakic and pseudophakic
Campo et al 1999	294	86%–91%	Median 20/40	Pseudophakic
Speicher et al 2000	78	94%	≥20/50 in 87%–88%	Pseudophakic
Brazitikos et al 2003	22	86%	Median 20/40	Phakic and pseudophakic
Schmidt et al 2003	205	71%	≥20/50 in 11%	Included PVR
Sharma et al 2004	48	81%	Mean 20/66	Inferior breaks
Martinez-Castillo, Verdugo, et al 2005	15	93%	Mean 20/30	Inferior breaks, pseudophakic, air as tamponade
Martinez-Castillo, Boixadera et al 2005	40	90%	Mean 20/33	Inferior breaks, pseudophakic, no facedown positioning
Heimann et al 2006	512	71%	≥20/50 in 48%	Included PVR, included some PPV/SB
Johansson et al 2006	131	87%	Mean 20/80	Phakic and pseudophakic
Martinez-Castillo et al 2007	60	98%	Mean 20/59	Pseudophakic, aqueous tamponade

Abbreviations: PPV/SB, combined pars plana vitrectomy/scleral buckling; PVR, proliferative vitreoretinopathy.

Adapted fromSPR Study Group (2003) and Schwartz and Flynn (2006).

Table 4 Selected retrospective comparative trials

Number of patients
Study	SB	PPV	SB and PPV	SOSR
Oshima et al 2000	55	47*	0	Equal (91% SB, 91% PPV)
Miki et al 2001	138	87*	0	Equal (92% SB, 92% PPV)
Roider et al 2001	60	10	30	Equivalent (98% SB, 93% PPV and SB/PPV combined)
Afrashi et al 2004	30	0	22**	Higher for SB/PPV (80% SB, 90% SB/PPV, p = 0.001)
Wickham et al 2004	0	41	45	Equivalent (89% PPV, 73% SB/PPV, p = 0.11)
Cheng et al 2006	92	19	0	Equivalent (85% SB, 95% PPV, no p value given)
Salicone et al 2006	26	0	18	Equivalent (62% SB, 72% SB/PPV, p = 0.17)
Weichel et al 2006	0	68	84	Equivalent (93% PPV, 94% SB/PPV, p = 0.75)

Abbreviations: PPV, Pars plana vitrectomy; RD, Retinal detachment; SB, Scleral buckling; SOSR, Single-operation success rate.

* In these 2 studies, most patients in the PPV group underwent PPV only; however, a small (unreported) number of patients underwent combined SB/PPV in each study.

** Used silicone oil as the tamponade agent. “Most” patients also underwent SB, but some were PPV only.

Adapted fromSPR Study Group (2003) and Schwartz and Flynn (2006).

Table 5 Selected prospective comparative trials

Number of patients
Study	SB	PPV	SB and PPV	Results
Tewari et al 2003*	20	0	20	Equivalent SOSR (70% SB, 80% SB/PPV, p = 0.72), equivalent vision (median 20/120 SB, 20/200 SB/PPV, p = 0.4)
Ahmadieh et al 2004*	126	99	0	Equivalent SOSR (68% SB, 63% PPV, p = 0.24), equal vision (mean 20/182 SB, 20/182 PPV)
Stangos et al 2004	0	45	26	Equivalent SOSR (98% PPV, 92% SB/PPV, no p value given), equivalent vision (improvement ≥3 lines in 60% PPV, 69% SB/PPV, no p value given)
Sharma et al 2005*	25	25	0	Equivalent SOSR (76% SB, 84% PPV, p = 0.48), better vision with PPV (20/105 SB, 20/71 PPV, p = 0.034)
Brazitikos et al 2005*	75	75	0	Higher SOSR for PPV (83% SB, 94% PPV, p = 0.037), equivalent vision (20/50 SB, 20/43 PPV, p = 0.26)

* Randomized trial.

Abbreviations: RD, Retinal detachment; PPV, Pars plana vitrectomy; SB, Scleral buckling; SOSR, Single-operation success rate.

Adapted from Schwartz and Flynn (2006).

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