PRIMARY SCLERAL BUCKLING FOR PEDIATRIC RHEGMATOGENOUS RETINAL DETACHMENT MARIE-HÉLÈNE ERRERA, MD, SIDATH E. LIYANAGE, FRCOPHTH, RENE MOYA, MD, S. CHIEN WONG, MBBS, FRCSED(OPHTH), ERIC EZRA, MA, MD, FRCS, FRCOPHTH Purpose: To evaluate the anatomical outcomes of primary scleral buckling (SB) procedures for pediatric rhegmatogenous retinal detachments. Methods: Retrospective consecutive case series. One hundred and four eyes of 99 consecutive nonselected pediatric patients undergoing primary SB were identified. Baseline factors recorded were demographics, presenting clinical examination findings, previous ocular surgery, predisposing factors. Intraoperative factors recorded were the type of buckle, number and distribution of retinal breaks, number of retinal quadrants detached, macular status (involved vs. uninvolved), the use of subretinal fluid drainage, and surgical complications. Anatomical reattachment rate at last follow-up. Subgroup analysis was carried out to identify any predisposing factors for failure of primary surgery, effect of age on outcome, intraoperative pathology, effect of posterior versus anterior SB, and redetachment and secondary-procedure complications specific to SB. Results: The initial surgery was segmental SB alone in 87 eyes (83.6%). Retinal reattachment was achieved with 1 operation in 73% (76 of 104 eyes). Of the 28 cases that redetached, 14 eyes underwent a repeat SB procedure (success rate of this second operation: 85.7% [12 of 14 eyes]), 13 eyes underwent vitrectomy (success rate of this second operation: 38.4% [5 of 13 eyes]), and 1 case was not reoperated. Overall, the final success rate was 94% (98 of 104 eyes). Factors associated with a statistically significant increased risk of failure included more than one break; three or more quadrants of detachment; horseshoe tears; no breaks seen on preoperative examination; Stickler syndrome. Conclusion: In selected cases, primary SB is an effective treatment for pediatric, rhegmatogenous retinal detachment. RETINA 35:1441–1449, 2015
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surgeries, and congenital or developmental abnormalities (Stickler syndrome, familial exudative vitreoretinopathy, Marfan syndrome, familial exudative vitreoretinopathy, and retinopathy of prematurity).2–4 The last 20 years have witnessed an evolution in the management of RRDs in adults with vitrectomy now superseding scleral buckling (SB) in most centers.5–7 Similar choices in surgical approach exist for pediatric RRDs, with SB being most prevalent (61%–76%) as an initial procedure in cases without advanced proliferative vitreoretinopathy (PVR).3,9–11 The use of both partial (segmental) and encircling explants have been described in this younger population.12–14 Indications for primary vitrectomy in pediatric eyes include poor fundal view because of vitreal opacities, severe PVR, and giant or posterior retinal breaks.10,15
hegmatogenous retinal detachment (RRD) is a major cause of blindness and ocular morbidity in adults. Despite this, it remains an uncommon occurrence in children and adolescents, ranging from 3% to 7% of all patients presenting with RRD.1 The incidence is 3 per 100,000 children per year with predisposing factors, including trauma, myopia, previous intraocular From the Department of Vitreoretinal Surgery, Moorfields Eye Hospital, London, United Kingdom. None of the authors have any financial/conflicting interests to disclose. M. -H. Errera and S. E. Liyanage contributed equally to the work, and therefore should be considered equivalent authors. Reprint requests: Eric Ezra, MA, MD, FRCS, FRCOphth, Department of Vitreoretinal Surgery, Moorfields Eye Hospital, 162 City Road, London EC1V 2PD, United Kingdom; e-mail: eric.ezra@ moorfields.nhs.uk
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Scleral buckling and vitrectomy can be combined as an initial approach in selected cases.16–19 In this retrospective study, we report the indications and outcomes of SB as a first-line treatment in the treatment of pediatric RRD.
Methods A retrospective case note review of all children aged 18 years or younger who underwent SB as an initial procedure for RRD at Moorfields Eye Hospital over a 13-year period, from October 1998 to September 2011. This study received Institutional Board approval from Moorfields Eye Hospital NHS Foundation Trust. The research adhered to the tenets of the Declaration of Helsinki. Data collected included demographics, presenting clinical examination findings, previous ocular surgery, predisposing factors, and anatomical outcome. Only cases with initial RRD repair by SB performed in Moorfields Eye Hospital were included in this study. Exclusion criteria included cases with significant PVR (triaged for primary pars plana vitrectomy); familial exudative vitreoretinopathy; and cases with previously diagnosed retinal breaks treated with laser procedure or previous vitrectomy for penetrating trauma. In certain patients, the clinical diagnosis of Stickler syndrome was made based on the presence of vitreous anomalies (either membranous or beaded) on slit-lamp biomicroscopy examination in combination with varying degrees of systemic abnormalities, including typical facial appearance, hearing loss, and joint problems. In cases of ocular trauma, the injury was classified according to the system proposed by Kuhn et al.21 The surgical procedure for SB is summarized by the following key steps: retinal cryopexy followed by the suturing of one or more solid silicone episcleral circumferential elements (tire) to the sclera (Labtician Ophthalmics Inc, Oakville, Ontario) in a break-ora occlusive method using hemi-Halsted mattress sutures.22 The width of elements used was 7, 9, or 11 mm, dependent on the location of the most posterior retinal break. A minimum distance of 1 mm was maintained between the most posterior retinal break and the posterior edge of the segmental element. This element could be combined with a 2.5-mm encircling band where deemed clinically necessary. Drainage was necessitated when the presence of subretinal fluid prevented apposition of the break and indent. The site of the drain was positioned in the area of maximal retinal elevation, preferably within the proposed site of the indent. The area was compressed for 1 minute before the drain to reduce the risk of choroidal hemorrhage. The drain was performed by using the needle of a 5-0 Ethibond suture (Ethicon, Bridgewater, NJ)
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to incise the sclera and choroid. Immediate pressure adjacent to the site facilitated drainage and reduced risk of hemorrhage. During drainage, the area was monitored for signs of incarceration and hemorrhage. The following perioperative factors were collected: number and distribution of retinal breaks; the number of retinal quadrants detached; macular status (involved vs. uninvolved); the use of internal gas tamponade and subretinal fluid drainage. A retinal break was defined as a full-thickness defect in the neural retina. Subcategories included horseshoe tears, round retinal holes, and dialyses. Horseshoe tears are breaks held open by vitreous traction, which remains adherent to the flap of the tear. Round operculated tears (complete avulsion of the flap or opercula because of traction) were classified in the horseshoe tear group. Round retinal holes are breaks secondary to retinal atrophy. Dialyses are breaks where the anterior and posterior edges are located at the ora serrata and vitreous base, respectively. The primary outcome was anatomical success, defined as a complete retinal reattachment without silicone oil. Secondary outcomes included the number of subsequent surgeries and the requirement of silicone oil to maintain retinal attachment. Visual acuity was not analyzed because of difficulties in accurately assessing and comparing visual acuity in this demographic in the setting of a retrospective review. Statistical comparisons were performed using the Fisher’s exact test for univariant data. A P , 0.05 was deemed as statistically significant. Results Baseline Analysis We identified 104 eyes in 99 children who underwent SB as an initial procedure for RRD. This included five patients with bilateral RRDs. The mean age was 12 years (median = 13 years; SD, 3.22; range, 1–18 years) with 79.5% of the patients being male. The mean follow-up interval was 25 months (median, 9 months), with followup ranging from 3 months to 13 years. There were 101 (98%) phakic eyes and 3 (2%) aphakic eyes. The majority of RRDs involved either 1 or 2 quadrants (40 eyes, 38.5%; and 32 eyes, 31%, respectively), whereas 3 quadrants were affected in 19 eyes (18%) and total RRD (4 quadrants) occurred in 13 eyes (12.5%). The macula was detached in 63 eyes (60.5%). Sixty-two percent of patients presented with symptoms of RRD, with the remaining patients found following a failed vision screening or optometrist-led vision test. Family ocular history was remarkable for RRD in family members for two children.
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Anatomical Success Rate
Table 2. Pediatric SB: Final Reattachment With Only SB
The anatomical success rate is summarized in Tables 1 and 2. The success rate for SB as a primary procedure was 73% (76 of 104 eyes) (Table 1). Of the 28 cases that redetached, 14 eyes underwent a repeat SB procedure, 13 eyes underwent vitrectomy, and 1 case was not reoperated (Table 1). Of vitrectomy cases, silicone oil was used in 11 (Table 1). Anatomical success rate of second operations was 85.7% (12 of 14 eyes) for SB (including encirclement), 38.4% (5 of 13 eyes) for vitrectomy. Final anatomical success rate was 100% (14 of 14 eyes) for SB (including encirclement), 54.5% (6 of 11 eyes) for vitrectomy with silicone oil, and 50% (1 of 2 eyes) for vitrectomy with gas (Table 3). Overall, complete retinal reattachment was achieved in 94% (98 of 104 eyes) (Table 1). Statistical analysis revealed that SB in cases with more than three quadrants of retinal detachment or more than one retinal break (including horseshoe tears, round holes, and dialyses) were more likely to fail (P , 0.05). Factors that did not statistically influence the outcome of anatomical success include the degree of myopia, macular status, previous intraocular surgery, self-injury, and eye poking in patients with severe developmental delay or autism (five patients). The initial surgery was segmental SB alone in 87 (83.6%) eyes. Sixty-five of 87 eyes (74%) reattached after 1 segmental SB procedure alone, versus 11 of 17 eyes (64.7%) after 1 encirclement or encirclement plus SB (P = 0.230, not statistically significant). Twentytwo eyes failed to reattach after 1 surgery with segmental SB alone (without encirclement), 4 of them never reattached.
Reattachment primary SB
Table 1. Anatomical Outcomes After Retinal Detachment Surgery in 104 Pediatric Cases Attending the Vitreoretinal Department at Moorfields Eye Hospital Over a 13-Year Period Reattachment Rates
Number
Final reattachment 98/104* Reattachment after first surgery 76/104 Reattachment at second 17/27† surgery Reattachment at third surgery 5/9‡ Second treatment SB (14/27), 51.8% 12/14 PPV (13/27), 48% 7/13 SO (11/13), 84.6% 6/11
Frequency (%) 94 73 63 55.5 86 54 54.5
*One eye with the detached retina was macula on under SO, one eye: the retina attached under SO was considered as detached. †Twenty-seven eyes underwent a second surgery, and the retina reattached in 17 of them. ‡One eye: retina attached under SO, considered as detached. PPV, pars plana vitrectomy; SO, silicone oil.
Reattachment primary SB without encirclement Reattachment primary SB + encirclement Reattachment after second SB Overall reattachment only SB
76/104 (73%) 65/87 11/17 12/14 (86%) 88/104 (85%)
17 eyes had a primary SB + encirclement, No eyes had .2 SB procedures
Success rates were comparable between the group treated with wide segmental explants for posterior breaks (9 or 11 mm) (14 eyes) versus the group treated with narrower segmental explants (7 mm) for more anterior breaks (90 eyes) (P = 1.000) (Table 8). Subretinal drainage was performed in 37.5% of cases that underwent SB and was not associated with statistically significant rates of reattachment (P = 0.827). Redetachment and Secondary Procedure Ten eyes needed more than 2 operations, with 8 eyes requiring 3 retinal detachment repairs (Tables 1 and 2). Unseen retinal breaks preoperatively or new breaks were the most frequent cause of retinal redetachment after the first operation in 12 eyes, followed by PVR (10 eyes), inadequate support from indentation in 6 eyes, with 4 as a consequence of fading of the buckle, and 2 due unsupported breaks (Table 6). Scleral buckling was performed as a secondary procedure in 51.8% of cases (Table 1), most commonly when the etiology was myopia (5 of 14 eyes, 35.7%) or trauma (4 of 14 eyes, 28.5%). This achieved reattachment in 85.7% of cases with similar success rates for both segmental and encircling elements (Table 3). Vitrectomy using either gas or oil was the secondary intervention in 48.2% of cases (Table 1), most commonly when the etiology was myopia (12 of 13 eyes, 92.3%), Stickler syndrome (6 of 6 eyes, 100%), or when the breaks had a round hole configuration (5 of 12 eyes, 41.6%) (Table 4). This modality achieved an overall reattachment rate of 54% (Table 1). Subgroups Analysis Predisposing factors to rhegmatogenous retinal detachment. Predisposing factors and their respective success rates are summarized in Table 4. Myopia was present in 44 eyes, 58% of which had high myopia (defined as .−6.00 diopters [D]). Primary
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Table 3. Surgical Procedure and Anatomical Results of Reoperation After Retinal Detachment Surgery in 27/104 Pediatric Cases That Failed Primary Surgery
Success rate after second operation Success rate at the end of intervention Further operations (3+)
SSB
SB + Encirclement
PPV + SO
PPV + Gas
7/8 (87.5%) 8/8 (100%) 1 PPV + gas
5/6 (83.3%) 6/6 (100%) 1 PPV + SO
6/11 (54.5%)* 9/11 (81%)‡ 3 PPV + SO
1/2 (50%)† 1/2 (50%) 0
*One eye: PPV + encirclement + SO, failed and then need for three PPV SO. †One eye: SB + PPV + gas, successfully reattached. ‡One eye: retina attached under SO. PPV, pars plana vitrectomy; SSB, segmental SB; SO, silicone oil.
reattachment rate was not statistically significant between myopic and highly myopic eyes (61 vs. 57.7%). Forty eyes (38.5%) presented after contusive closed globe injuries, while the clinical diagnosis of Stickler syndrome was made in 12 patients. Other associated conditions included retinal dystrophy (4 patients), Marfan syndrome (3 patients), Trisomy 21 (2 patients), uveitis (2 patients), and retinopathy of prematurity (1 patient). Three patients had a history of previous cataract surgery. The etiology of the retinal detachment was unknown in 27 eyes. Further analysis according to the underlying predisposing factors showed that the success rate after the first operation was higher in trauma (80%), after previous cataract surgery (100%), and eyes with no predisposing factors to RD (77%). Among those with no risks factors, three eyes did not reattach after first surgery and two of them never reattached. The reattachment rate was the lowest in the Stickler group (50%). These were not statistically significant.
Type of Retinal Tears at Baseline and Its Implications A definite retinal break was identified in 97 eyes (93.2%), of which 34 eyes (32.6%) had multiple breaks (Tables 5 and 6). Dialyses were most frequently identified (56 eyes), of which 27 were associated with trauma (closed globe) and 15 with myopia. Round holes were identified in 38 eyes, of which 23 were associated with myopia and lattice degeneration, 12 with trauma, and 6 with Stickler syndrome. Seven eyes presented with horseshoe tears. No breaks were seen in seven eyes (6%). Scleral buckling was successful after the first procedure in 82% of RRDs secondary to dialyses, and 68.4% of retinal detachments secondary to round holes. The anatomical success rate was worse in eyes where no breaks were preoperatively detectable and in RRD secondary to horseshoe tears (57 and 28.6%, respectively). Indeed, 28.6% (2 of 7 eyes) only of
Table 4. Clinical Characteristics and Surgical Outcomes After Retinal Surgery in 104 Pediatrics Cases
No.
Primary Reattachment Rate
Trauma
40*
32/40 (80%)
High myopia, (.−6 D) (inc Marfan) Myopia (#−6 D)
26 18
11/18 (61%)
Stickler syndrome
12‡
6/12 (50%)
39, 21/39 suspected trauma, for example, dialysis, eye-rubbing, head slapping 3
30/39 (77%)
Predisposing Factor
No specific underlying cause/other Previous intraocular surgery‡
PVR, PPV + SO at Second Operation
Final Reattachment Rate
1/6 PVR, 1/6 PPV + 38/40* (95%) SO 15/26 (57.7%) 4/11 PVR, 8/11 PPV 22/26† (84.6%), 1.25 Sx + SO per eye after initial SB
3/3 (100%)
3/7 PVR, 4/7 PPV + 17/18 (94.4%) SO 1/6 PVR, 5/6 PPV + 12/12 (100%), 1.3 Sx per SO eye after initial SB 3/10 PVR, 2/10 PPV 39/39 (100%), 1.22 Sx + SO among eyes reoperated — 3/3 (100%), no second operation
The total number of eyes does not match 104 eyes because some eyes with several associated conditions. Primary reattachment rate not statistically significant between myopic and high myopic eyes (P = 1.000). *One attached in oil. †Two attached in oil. ‡Cataracts treated by lensectomy (two eyes), phacoemulsification combined with glaucoma surgery (one eye). PPV, pars plana vitrectomy; Sx, surgeries.
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SCLERAL BUCKLING FOR RETINAL DETACHMENT ERRERA ET AL
Table 5. Intraoperative Clinical Characteristics (Break Type) in 104 Pediatric Cases and Anatomical Outcomes (Reoperation) After Retinal Detachment Surgery n (Eyes)
Type of Break
Primary Reattachment Rate
Dialysis
56*
46/56 (82%)
Round holes
38*
26/38 (68.4%)
HST Unseen breaks or suspicious breaks
7 7
2/7 (28.6%) 4/7 (57%)
Final Reattachment 3+ Rate PPV at Second Operation Operations 54/56 (96.4%)† 35/38† (92%) 7/7† (100%) 5/7 (71%)**
PPV‡ (2/10), SO (2/10), SB (8/10) PPV‡ (5/12), SO (4/12), SB (3/12) PPV‡ (4/5), SO (4/5) PPV (2/3)††, SO (1/3)
0 3§ 1 1
*Two eyes: dialysis + round hole, two eyes: dialysis + HST. †Two eyes with retina attached under SO at the end of follow-up considered as detached. ‡PPV, SO because scleral rupture during SB for RRD recurrence. §Two eyes had three operations to reattach the retina (·1 SB then ·1 PPV with SO or gas), one eye had five operations: ·1 PPV + encirclement and SO, followed by ·3 surgeries by PPV and SO). † **One eye had no further treatment after SB as the first operation due to PVR. ††Two eyes had a reoperation by PPV. Two eyes had recurrence of RRD but no further surgery. HST, horseshoe tear; PPV, pars plana vitrectomy; SO, Silicone oil.
horseshoe tears closed with primary SB, and 4 of 5 eyes needed vitrectomy as a secondary procedure. The final reattachment rate ranged between 92% and 100% depending on the type of break, with the exception of the group presenting with unseen breaks (71%). Effect of age on outcome. Population characteristics and anatomical success rates of SB between 3 different age groups were analyzed: 0 years to 10 years; 11 years to 15 years; 16 years to 18 years (Table 7). Children belonging to the youngest group were most likely to present with an RRD involving the macula (77 vs. 45.3 vs. 50%). As the age increased, there was a trend toward an increase in success rates at either first (70 vs. 76 vs. 85.7%) or second surgery attempt (55.5 vs. 78.6 vs. 100%).
Effect of posterior versus anterior scleral buckling. Posterior equatorial breaks were treated with a wide segmental explant (9 and 11 mm) and comprised 13.6% (14 eyes) of the eyes (Table 8). Anatomical success rates were comparable between this group and the group with more anterior breaks treated with narrower segmental explants (7 mm) (90 eyes); success rate after first surgery was 71% and 73%, respectively (P = 1.000). Complications specific to scleral buckling. Scleral buckling–related complications occurred in seven cases (7%) and included retinal incarceration (two eyes), vertical diplopia and exotropia (three patients), iris incarceration in paracentesis (performed to lower intraocular pressure after suturing explant) in one eye and episcleritis (one eye).
Table 6. Intraoperative Clinical Characteristics in 104 Pediatric Cases, Anatomical Outcomes and Cause of Redetachment After Retinal Detachment Surgery
Type of Break
n (Eyes)
Subgroups
Primary Reattachment Rate
Dialysis
56*
Trauma (27), Myopia (15), (7 .−6 D), Stickler syndrome (1), Down syndrome (1)
46/56 (82%)
Round holes
38*
Myopia (23), (16 .−6 D), trauma (12), Stickler syndrome (6), retinal dystrophy (4), ROP (1) High myopia (2), Stickler syndrome (2), trauma (1), retinal dystrophy (1), Uveitis (1) Myopia (3), 6 .−6 D, Stickler (1), retinal dystrophy (1), after cataract surgery (2)
26/38 (70%)
HST
7
Unseen breaks or suspicious breaks
7
Causes of Redetachment
2/7 (29%)
New break (4), unsupported/faded indent (3), PVR (3) New break (7), faded indent (3), PVR (4) New break (1), PVR (1)
4/7 (57%)
New break (2), PVR (2)
*Two eyes presented dialysis and round hole associated; two eyes presented dialysis and HST associated. In two eyes, the retina remained detached at the end of follow-up. In eyes with round holes, among those who detached two eyes remained detached eventually at the end of follow-up. In eyes with dialysis, among the eyes whose retina redetached, they all went flat eventually. D, diopter; HST, horseshoe tear; ROP, retinopathy of prematurity.
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Table 7. Outcome Versus Age Age Groups
Group I, 0–10, 26 Eyes
Group II, 11–15, 64 Eyes
Group III, 16–18, 14 Eyes
Mean age (years) Predisposing factors
8
13
16.5
Macula off PVR Success rate after first surgery Final success rate Sucess rate at second surgery Use of PPV at second surgery Use of SO
High myopia (8), myopia (1), trauma (10), Stickler (5), retinal dystrophies (2) 77% (20) 3.8% (1) 61.5% (16/26)
High myopia (7), myopia (10), trauma High myopia (1), myopia (4), trauma (5), Stickler (1), other (3): after (23), Stickler (6), others (18): after cataract surgery (1), retinal cataract surgery, retinal dystrophy or dystrophy (2) others 45.3% (29) 50% (7) 11% (7) 14.3% (2) 76% (48/64) 85.7% (12/14)
92.3% (24/26)*
90.6% (58/64)†
100% (15/15)
55.5% (5/9)‡
78.6% (12/16)§
100% (2/2)
66% (6/9)
35.7% (5/14)
100% (2/2)
6/6
3/5
2/2
*One detached, one attached in SO, one detached in SO macula on. †One attached in SO. ‡Nine reoperated. §Fourteen reoperated. PPV, pars plana vitrectomy; SO, silicone oil.
Two cases of scleral rupture occurred during indentation to mark the breaks or because of a deep suture, with one case requiring further vitrectomy. Vertical diplopia induced by segmental SB occurred in two patients, with one resolving while the other
required strabismus surgery. Surgical repositioning was performed for the iris incarceration occurring during anterior chamber paracentesis. There were three cases of delayed resorption of subretinal fluid, defined as being present beyond the first postoperative month.
Table 8. Outcomes: Anterior Versus Posterior SB Group 1, Width of Element 9 to 11 mm, 14 Eyes Predisposing factors Dialysis*† Round hole* HST Success rate after first surgery Final success rate Success rate at second surgery Use of vitrectomy at second surgery Use of SO among vitrectomized eyes at second surgery
Group 2, Width of Element 7 mm, 90 Eyes
P
Trauma (6), high myopia (3), Trauma (34), high myopia (23), myopia (15), Stickler myopia (2), Stickler (2) (10), others (3): after cataract surgery, retinal dystrophy 8 48 6 32 1 6 71.4% (10/14) 73.3% (66/90) 1.000 100% (14/14) 75% (3/4)
95.5% (86/90)‡ 65.2% (15/23)
1.000 1.000
0/4§
56.5% (13/23)¶
0.2844
—
84.6% (11/13)
—
*One eye coexistence round hole + dialysis. †One eye coexistence HST + dialysis. ‡Two eyes considered as “attached”. §Four eyes reoperated. ¶One eye (Eye no. 5: the use of vitrectomy SO at second operation because scleral rupture during cryo-buckling at second operation). HST, horseshoe tear; SO, silicone oil.
SCLERAL BUCKLING FOR RETINAL DETACHMENT ERRERA ET AL
In all three cases, the subretinal fluid resolved within 1 year. There were no cases of explant extrusion during the follow-up period.
Discussion Scleral buckling is a common primary intervention for pediatric RRDs, associated with high success and low complication rates.3 In contrast to adults, in whom the liquefied vitreous and tractional forces allow the accumulation of subretinal fluid (20), the vitreous in the pediatric population is usually nonsyneretic. The presence of a horseshoe tear in this population suggests an anomalous vitreous liquefaction, which may develop after trauma23 or in association with genetic vitreoretinopathies and myopia.24 The presence of nonsyneretic vitreous can influence the outcome of SB, by having a tamponading effect on retinal breaks after the relief of vitreous traction by scleral indentation. We describe the anatomical outcomes in 104 eyes of 99 children who underwent SB for RRD. Previous studies have usually used SB with encircling bands, and in this study, encirclement was used in only 17 of 104 eyes (16%) as the primary intervention in this pediatric population; the remainder underwent SB with a segmental explant only. Although the outcomes of RRD in the pediatric population have been previously described, these studies have either combined the results of SB and vitrectomy as a primary intervention3,9,18,19 or collated the outcomes of SB with primarily encirclement alone.10,15,25–27 Our primary anatomical success rate of 73% with SB alone and a final anatomical success rate of 94% are comparable with published outcomes ranging from 83% to 100% using SB alone in pediatric RRD.10,11,15,22,27 As previously reported,10 as the age increased, there was a trend toward an increase in success rates at either the first or second surgery attempt. Our results are also comparable with those studies that combine the final outcomes of both vitrectomy and SB in children (75%–79%).3,18,19 There is strong support for the use of encirclement as the standard primary procedure for pediatric RRDs, with studies such as Wadhwa et al15 (85 eyes) and Ripandelli et al26 (154 eyes) using this modality in 100% and 97% of cases, respectively. In contrast to this, our study used segmental SB in 84% of cases and showed that similar high success rates (74% anatomical success and 95% final reattachment) are achievable without using encirclement in most of them. The advantages of the latter include a less extensive surgical approach and a lower incidence of buckle-related
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complications (change in refractive error, diplopia, choroidal detachments, anterior segment ischemia, and glaucoma).28 Vitrectomy has been suggested as an intervention for more posterior retinal breaks. In our study, subgroups’ analysis of anterior (narrow segmental explants, 7 mm) versus posterior (wider segmental explant, 9 and 11 mm) type of segmental SB showed no difference in anatomical success rates after first surgery (73 vs. 73%) and in final success rate (95.5 vs. 100%). Our study highlights that segmental SB with a wider explant could offer an effective alternative to vitrectomy in this cohort of patients. Predisposing factors were identified in 62.5% of our cases, comparable with other similar studies.9,10,15,18 Myopia (44%) and trauma (38.5%) were most common, with primary reattachment rates of 59.5% and 80%, respectively. Of note, there was no statistically significant difference in outcomes between myopia and high myopia (.−6 D). In our series, round holes were more commonly seen in myopic children as reported by other authors.3 Interestingly, the majority of cases developing PVR occurred in this group (58% of PVR overall) accounting for the majority of failures. We found that only 48% of patients with dialysis had a history of trauma. The high incidence of retinal dialyses in the absence of reported trauma has been noted by other authors, although the precipitating event may be unreported because of the age of the patient.26 The primary success rate of SB for RRD secondary to dialysis (82%) and round holes (68.4%) was better than those because of horseshoe tears (28.57%) or when no breaks were detected preoperatively (57%). The presence of horseshoe tears in the pediatric population is highly unusual, and as mentioned earlier, may reflect an abnormal etiology (e.g., genetic vitreoretinopathies) with consequent lower success rates. Similarly in this study, factors that increased the level of complexity, such as multiple retinal breaks and more extensive RRDs, are associated with higher risks of redetachments. Our patients with Stickler syndrome had the lowest success rate (50%), consistent with the findings by Chen et al4 that patients with congenital abnormalities have a lower success rate with SB. This reduced success rate may reflect the anomalous nature of the vitreous in this condition, necessitating either encirclement or vitrectomy. As success in segmental SB depends on a sitespecific treatment effect, it is understandable that retinal breaks not identified preoperatively were the most frequent causes of retinal redetachment after the first operation (12 eyes). Remaining failures were
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accounted for by PVR in 10 eyes and inadequate indent support in 6 eyes—premature fading of the buckle in 4 eyes, and the presence of unsupported breaks in 2 eyes. Scleral buckling was performed as a secondary procedure in 51.8% of cases, most commonly when the etiology was trauma (36%) or myopia (27%) or unknown (27%). This achieved reattachment in 85.7% of cases with similar success rates for both segmental and encircling elements. Vitrectomy using either gas or oil was the secondary intervention in 48.2% of cases, most commonly when the etiology was myopia (61%). This modality achieved reattachment in only 54% of cases. The trend toward a lower rate may be attributed to the more complex case mix of eyes undergoing vitrectomy. This study shows that SB is an effective primary intervention in pediatric RRDs, associated with a primary anatomical success rate of 73% after 1 operation and a final reattachment rate of 94%. In contrast to much of the published literature on this subject, the majority of SB procedures used a segmental explant (84%) as opposed to encirclement. As such, the results from this study reassure in proposing segmental SB as a primary intervention for pediatric RRD. This study has highlighted risk factors that reduce the success rates in this specific modality of segmental SB: no breaks identified preoperatively; horseshoe tears; multiple retinal breaks; more than three quadrants of RRD; and Stickler syndrome. Cases presenting with these factors would benefit from either SB using encirclement or pars plana vitrectomy. If the cases with these risk factors are excluded from our analysis (resulting in 40 cases in total), segmental SB results in a primary anatomical success rate of 93% after 1 operation and a final reattachment rate of 95%. In conclusion, this study on primary SB for pediatric RRD in 104 cases shows results comparable with the published literature, with a primary and final anatomical success rate of 73% and 94%, respectively. This confirms that SB represents an excellent choice as a first-line treatment in pediatric RRDs. Of note, this study also highlights the successful use of segmental SB as a viable alternative to SB with encirclement or vitrectomy in selected cases with localized pathology. Key words: retinal detachment, pediatric, scleral buckling. Acknowledgments The authors thank Mr. Paul Sullivan, Vitreoretinal Consultant in Moorfields Eye Hospital, for his help in revising the article.
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References 1. Häring G, Wiechens B. Long-term results after scleral buckling surgery in uncomplicated juvenile retinal detachment without proliferative vitreoretinopathy. Retina 1998;18:501–505. 2. Rosner M, Treister G, Belkin M. Epidemiology of retinal detachment in childhood and adolescence. J Pediatr Ophthalmol Strabismus 1987;24:42–44. 3. Chang PY, Yang CM, Yang CH, et al, Clinical characteristics and surgical outcomes of pediatric rhegamtogenous retinal detachment in Taiwan. Am J Ophthalmol 2005;139: 1067–1072. 4. Chen SN, Jiunn-Feng H, Te-Cheng Y. Pediatric rhegmatogenous retinal detachment in Taiwan. Retina 2006;26:410–414. 5. Rumelt S, Sarrazin L, Averbukh E, et al, Paediatric vs adult retinal detachment. Eye (Lond) 2007;21:1473–1478. 6. Miki D, Hida T, Hotta K, et al. Comparison of scleral buckling and vitrectomy for retinal detachment resulting from flap tears in superior quadrants. Jpn J Ophthalmol 2001;45:187–191. 7. Minihan M, Tanner V, Williamson TH. Primary rhegmatogenous retinal detachment: 20 years of change. Br J Ophthalmol 2001;85:546–548. 8. Oshima Y, Yamanishi S, Sawa M, et al. Two-year follow-up study comparing primary vitrectomy with scleral buckling for macula-off rhegmatogenous retinal detachment. Jpn J Ophthalmol 2000;44:538–549. 9. Fivgas GD, Capone A. Pediatric rhegmatogenous retinal detachment. Retina 2001;21:101–106. 10. Wang NK, Tsai CH, Chen YP, et al, Pediatric rhegmatogenous retinal detachment in east Asians. Ophthalmology 2005;112: 1891–1896. 11. Yokoyama T, Kato T, Minamoto A, et al. Characteristics and surgical outcomes of paediatric retinal detachement. Eye (Lond) 2004;18:889–892. 12. Bodard GE, Pasticier A, Biojout G, et al. Prognosis of retinal detachment in children [in French] J Fr Ophtalmol 1978;1: 589–595. 13. Lemrini F, Dafrallah L, Kabbaj A. Retinal detachment in children [in French]. J Fr Ophtalmol 1993;16:159–164. 14. Winslow RL, Tasman W. Juvenile rhegmatogenous retinal detachment. Ophthalmology 1978;85:607–618. 15. Wadhwa N, Venkatesh P, Sampangi R, et al. Rhegmatogenous retinal detachments in children in India: clinical characteristics, risk factors, and surgical outcomes. J AAPOS 2008;12:551–554. 16. Ferrone PJ, McCuen BW, de Juan E, et al. The efficacy of silicone oil for complicated retinal detachments in the pediatric population. Arch Ophthalmol 1994;112:773–777. 17. Moisseiev J, Vidne 0, Treister G. Vitrectomy and silicone oil injection in pediatric patients. Retina 1998;18:221–227. 18. Soheilian M, Ramezani A, Malihi M, et al. Clinical features and surgical outcomes of pediatric rhegmatogenous retinal detachment. Retina 2009;29:545–551. 19. Weinberg DV, Lyon AT, Greenwald MJ, et al. Rhegmatogenous retinal detachments in children: risk factors and surgical outcomes. Ophthalmology 2003;110:1708–1713. 20. Ghazi NG, Green WR. Pathology and pathogenesis of retinal detachment. Eye (Lond) 2002;16:411–421. 21. Kuhn F, Morris R, Witherspoon CD, et al. A standardized classification of ocular trauma. Ophthalmology 1996;103: 240–243. 22. Gilbert C, McLeod D. D-ACE surgical sequence for selected bullous retinal detachments. Br J Ophthalmol 1985;69:733–736.
SCLERAL BUCKLING FOR RETINAL DETACHMENT ERRERA ET AL 23. Kuhn F, Aylward B. Rhegmatogenous retinal detachment: a reappraisal of its pathophysiology and treatment. Ophthalmic Res 2014;51:15–31698. 24. Sebag J. Anomalous posterior vitreous detachment: a unifying concept in vitreo-retinal disease. Graefes Arch Clin Exp Ophthalmol 2004;242:690. 25. Sadeh AD, Dotan G, Bracha R, et al. Characteristics and outcomes of paediatric rhegmatogenous retinal detachment treated by segmental scleral buckling plus an encircling element. Eye (Lond) 2001;15:31–33.
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26. Ripandelli G, Bruno M, Cupo G, et al. Childhood idiopathic retinal detachment: surgical procedures and postoperative outcomes after long-term follow-up. Retina 2010;30:1144–1151. 27. Kocaoglan H, Unlü N, Acar MA, et al. The efficacy of conventional rhegmatogenous retinal detachment surgery in the pediatric population. J Pediatr Ophthalmol Strabismus 2003; 40:4–5. 28. Williams GA, Aaberg TM. Techniques of scleral buckling. In: Ryan Stephen J, eds. Retina. Vol 2. Saunders; 2005:2010– 2046.
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surgeries, and congenital or developmental abnormalities (Stickler syndrome, familial exudative vitreoretinopathy, Marfan syndrome, familial exudative vitreoretinopathy, and retinopathy of prematurity).2–4 The last 20 years have witnessed an evolution in the management of RRDs in adults with vitrectomy now superseding scleral buckling (SB) in most centers.5–7 Similar choices in surgical approach exist for pediatric RRDs, with SB being most prevalent (61%–76%) as an initial procedure in cases without advanced proliferative vitreoretinopathy (PVR).3,9–11 The use of both partial (segmental) and encircling explants have been described in this younger population.12–14 Indications for primary vitrectomy in pediatric eyes include poor fundal view because of vitreal opacities, severe PVR, and giant or posterior retinal breaks.10,15
hegmatogenous retinal detachment (RRD) is a major cause of blindness and ocular morbidity in adults. Despite this, it remains an uncommon occurrence in children and adolescents, ranging from 3% to 7% of all patients presenting with RRD.1 The incidence is 3 per 100,000 children per year with predisposing factors, including trauma, myopia, previous intraocular From the Department of Vitreoretinal Surgery, Moorfields Eye Hospital, London, United Kingdom. None of the authors have any financial/conflicting interests to disclose. M. -H. Errera and S. E. Liyanage contributed equally to the work, and therefore should be considered equivalent authors. Reprint requests: Eric Ezra, MA, MD, FRCS, FRCOphth, Department of Vitreoretinal Surgery, Moorfields Eye Hospital, 162 City Road, London EC1V 2PD, United Kingdom; e-mail: eric.ezra@ moorfields.nhs.uk
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Scleral buckling and vitrectomy can be combined as an initial approach in selected cases.16–19 In this retrospective study, we report the indications and outcomes of SB as a first-line treatment in the treatment of pediatric RRD.
Methods A retrospective case note review of all children aged 18 years or younger who underwent SB as an initial procedure for RRD at Moorfields Eye Hospital over a 13-year period, from October 1998 to September 2011. This study received Institutional Board approval from Moorfields Eye Hospital NHS Foundation Trust. The research adhered to the tenets of the Declaration of Helsinki. Data collected included demographics, presenting clinical examination findings, previous ocular surgery, predisposing factors, and anatomical outcome. Only cases with initial RRD repair by SB performed in Moorfields Eye Hospital were included in this study. Exclusion criteria included cases with significant PVR (triaged for primary pars plana vitrectomy); familial exudative vitreoretinopathy; and cases with previously diagnosed retinal breaks treated with laser procedure or previous vitrectomy for penetrating trauma. In certain patients, the clinical diagnosis of Stickler syndrome was made based on the presence of vitreous anomalies (either membranous or beaded) on slit-lamp biomicroscopy examination in combination with varying degrees of systemic abnormalities, including typical facial appearance, hearing loss, and joint problems. In cases of ocular trauma, the injury was classified according to the system proposed by Kuhn et al.21 The surgical procedure for SB is summarized by the following key steps: retinal cryopexy followed by the suturing of one or more solid silicone episcleral circumferential elements (tire) to the sclera (Labtician Ophthalmics Inc, Oakville, Ontario) in a break-ora occlusive method using hemi-Halsted mattress sutures.22 The width of elements used was 7, 9, or 11 mm, dependent on the location of the most posterior retinal break. A minimum distance of 1 mm was maintained between the most posterior retinal break and the posterior edge of the segmental element. This element could be combined with a 2.5-mm encircling band where deemed clinically necessary. Drainage was necessitated when the presence of subretinal fluid prevented apposition of the break and indent. The site of the drain was positioned in the area of maximal retinal elevation, preferably within the proposed site of the indent. The area was compressed for 1 minute before the drain to reduce the risk of choroidal hemorrhage. The drain was performed by using the needle of a 5-0 Ethibond suture (Ethicon, Bridgewater, NJ)
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to incise the sclera and choroid. Immediate pressure adjacent to the site facilitated drainage and reduced risk of hemorrhage. During drainage, the area was monitored for signs of incarceration and hemorrhage. The following perioperative factors were collected: number and distribution of retinal breaks; the number of retinal quadrants detached; macular status (involved vs. uninvolved); the use of internal gas tamponade and subretinal fluid drainage. A retinal break was defined as a full-thickness defect in the neural retina. Subcategories included horseshoe tears, round retinal holes, and dialyses. Horseshoe tears are breaks held open by vitreous traction, which remains adherent to the flap of the tear. Round operculated tears (complete avulsion of the flap or opercula because of traction) were classified in the horseshoe tear group. Round retinal holes are breaks secondary to retinal atrophy. Dialyses are breaks where the anterior and posterior edges are located at the ora serrata and vitreous base, respectively. The primary outcome was anatomical success, defined as a complete retinal reattachment without silicone oil. Secondary outcomes included the number of subsequent surgeries and the requirement of silicone oil to maintain retinal attachment. Visual acuity was not analyzed because of difficulties in accurately assessing and comparing visual acuity in this demographic in the setting of a retrospective review. Statistical comparisons were performed using the Fisher’s exact test for univariant data. A P , 0.05 was deemed as statistically significant. Results Baseline Analysis We identified 104 eyes in 99 children who underwent SB as an initial procedure for RRD. This included five patients with bilateral RRDs. The mean age was 12 years (median = 13 years; SD, 3.22; range, 1–18 years) with 79.5% of the patients being male. The mean follow-up interval was 25 months (median, 9 months), with followup ranging from 3 months to 13 years. There were 101 (98%) phakic eyes and 3 (2%) aphakic eyes. The majority of RRDs involved either 1 or 2 quadrants (40 eyes, 38.5%; and 32 eyes, 31%, respectively), whereas 3 quadrants were affected in 19 eyes (18%) and total RRD (4 quadrants) occurred in 13 eyes (12.5%). The macula was detached in 63 eyes (60.5%). Sixty-two percent of patients presented with symptoms of RRD, with the remaining patients found following a failed vision screening or optometrist-led vision test. Family ocular history was remarkable for RRD in family members for two children.
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Anatomical Success Rate
Table 2. Pediatric SB: Final Reattachment With Only SB
The anatomical success rate is summarized in Tables 1 and 2. The success rate for SB as a primary procedure was 73% (76 of 104 eyes) (Table 1). Of the 28 cases that redetached, 14 eyes underwent a repeat SB procedure, 13 eyes underwent vitrectomy, and 1 case was not reoperated (Table 1). Of vitrectomy cases, silicone oil was used in 11 (Table 1). Anatomical success rate of second operations was 85.7% (12 of 14 eyes) for SB (including encirclement), 38.4% (5 of 13 eyes) for vitrectomy. Final anatomical success rate was 100% (14 of 14 eyes) for SB (including encirclement), 54.5% (6 of 11 eyes) for vitrectomy with silicone oil, and 50% (1 of 2 eyes) for vitrectomy with gas (Table 3). Overall, complete retinal reattachment was achieved in 94% (98 of 104 eyes) (Table 1). Statistical analysis revealed that SB in cases with more than three quadrants of retinal detachment or more than one retinal break (including horseshoe tears, round holes, and dialyses) were more likely to fail (P , 0.05). Factors that did not statistically influence the outcome of anatomical success include the degree of myopia, macular status, previous intraocular surgery, self-injury, and eye poking in patients with severe developmental delay or autism (five patients). The initial surgery was segmental SB alone in 87 (83.6%) eyes. Sixty-five of 87 eyes (74%) reattached after 1 segmental SB procedure alone, versus 11 of 17 eyes (64.7%) after 1 encirclement or encirclement plus SB (P = 0.230, not statistically significant). Twentytwo eyes failed to reattach after 1 surgery with segmental SB alone (without encirclement), 4 of them never reattached.
Reattachment primary SB
Table 1. Anatomical Outcomes After Retinal Detachment Surgery in 104 Pediatric Cases Attending the Vitreoretinal Department at Moorfields Eye Hospital Over a 13-Year Period Reattachment Rates
Number
Final reattachment 98/104* Reattachment after first surgery 76/104 Reattachment at second 17/27† surgery Reattachment at third surgery 5/9‡ Second treatment SB (14/27), 51.8% 12/14 PPV (13/27), 48% 7/13 SO (11/13), 84.6% 6/11
Frequency (%) 94 73 63 55.5 86 54 54.5
*One eye with the detached retina was macula on under SO, one eye: the retina attached under SO was considered as detached. †Twenty-seven eyes underwent a second surgery, and the retina reattached in 17 of them. ‡One eye: retina attached under SO, considered as detached. PPV, pars plana vitrectomy; SO, silicone oil.
Reattachment primary SB without encirclement Reattachment primary SB + encirclement Reattachment after second SB Overall reattachment only SB
76/104 (73%) 65/87 11/17 12/14 (86%) 88/104 (85%)
17 eyes had a primary SB + encirclement, No eyes had .2 SB procedures
Success rates were comparable between the group treated with wide segmental explants for posterior breaks (9 or 11 mm) (14 eyes) versus the group treated with narrower segmental explants (7 mm) for more anterior breaks (90 eyes) (P = 1.000) (Table 8). Subretinal drainage was performed in 37.5% of cases that underwent SB and was not associated with statistically significant rates of reattachment (P = 0.827). Redetachment and Secondary Procedure Ten eyes needed more than 2 operations, with 8 eyes requiring 3 retinal detachment repairs (Tables 1 and 2). Unseen retinal breaks preoperatively or new breaks were the most frequent cause of retinal redetachment after the first operation in 12 eyes, followed by PVR (10 eyes), inadequate support from indentation in 6 eyes, with 4 as a consequence of fading of the buckle, and 2 due unsupported breaks (Table 6). Scleral buckling was performed as a secondary procedure in 51.8% of cases (Table 1), most commonly when the etiology was myopia (5 of 14 eyes, 35.7%) or trauma (4 of 14 eyes, 28.5%). This achieved reattachment in 85.7% of cases with similar success rates for both segmental and encircling elements (Table 3). Vitrectomy using either gas or oil was the secondary intervention in 48.2% of cases (Table 1), most commonly when the etiology was myopia (12 of 13 eyes, 92.3%), Stickler syndrome (6 of 6 eyes, 100%), or when the breaks had a round hole configuration (5 of 12 eyes, 41.6%) (Table 4). This modality achieved an overall reattachment rate of 54% (Table 1). Subgroups Analysis Predisposing factors to rhegmatogenous retinal detachment. Predisposing factors and their respective success rates are summarized in Table 4. Myopia was present in 44 eyes, 58% of which had high myopia (defined as .−6.00 diopters [D]). Primary
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Table 3. Surgical Procedure and Anatomical Results of Reoperation After Retinal Detachment Surgery in 27/104 Pediatric Cases That Failed Primary Surgery
Success rate after second operation Success rate at the end of intervention Further operations (3+)
SSB
SB + Encirclement
PPV + SO
PPV + Gas
7/8 (87.5%) 8/8 (100%) 1 PPV + gas
5/6 (83.3%) 6/6 (100%) 1 PPV + SO
6/11 (54.5%)* 9/11 (81%)‡ 3 PPV + SO
1/2 (50%)† 1/2 (50%) 0
*One eye: PPV + encirclement + SO, failed and then need for three PPV SO. †One eye: SB + PPV + gas, successfully reattached. ‡One eye: retina attached under SO. PPV, pars plana vitrectomy; SSB, segmental SB; SO, silicone oil.
reattachment rate was not statistically significant between myopic and highly myopic eyes (61 vs. 57.7%). Forty eyes (38.5%) presented after contusive closed globe injuries, while the clinical diagnosis of Stickler syndrome was made in 12 patients. Other associated conditions included retinal dystrophy (4 patients), Marfan syndrome (3 patients), Trisomy 21 (2 patients), uveitis (2 patients), and retinopathy of prematurity (1 patient). Three patients had a history of previous cataract surgery. The etiology of the retinal detachment was unknown in 27 eyes. Further analysis according to the underlying predisposing factors showed that the success rate after the first operation was higher in trauma (80%), after previous cataract surgery (100%), and eyes with no predisposing factors to RD (77%). Among those with no risks factors, three eyes did not reattach after first surgery and two of them never reattached. The reattachment rate was the lowest in the Stickler group (50%). These were not statistically significant.
Type of Retinal Tears at Baseline and Its Implications A definite retinal break was identified in 97 eyes (93.2%), of which 34 eyes (32.6%) had multiple breaks (Tables 5 and 6). Dialyses were most frequently identified (56 eyes), of which 27 were associated with trauma (closed globe) and 15 with myopia. Round holes were identified in 38 eyes, of which 23 were associated with myopia and lattice degeneration, 12 with trauma, and 6 with Stickler syndrome. Seven eyes presented with horseshoe tears. No breaks were seen in seven eyes (6%). Scleral buckling was successful after the first procedure in 82% of RRDs secondary to dialyses, and 68.4% of retinal detachments secondary to round holes. The anatomical success rate was worse in eyes where no breaks were preoperatively detectable and in RRD secondary to horseshoe tears (57 and 28.6%, respectively). Indeed, 28.6% (2 of 7 eyes) only of
Table 4. Clinical Characteristics and Surgical Outcomes After Retinal Surgery in 104 Pediatrics Cases
No.
Primary Reattachment Rate
Trauma
40*
32/40 (80%)
High myopia, (.−6 D) (inc Marfan) Myopia (#−6 D)
26 18
11/18 (61%)
Stickler syndrome
12‡
6/12 (50%)
39, 21/39 suspected trauma, for example, dialysis, eye-rubbing, head slapping 3
30/39 (77%)
Predisposing Factor
No specific underlying cause/other Previous intraocular surgery‡
PVR, PPV + SO at Second Operation
Final Reattachment Rate
1/6 PVR, 1/6 PPV + 38/40* (95%) SO 15/26 (57.7%) 4/11 PVR, 8/11 PPV 22/26† (84.6%), 1.25 Sx + SO per eye after initial SB
3/3 (100%)
3/7 PVR, 4/7 PPV + 17/18 (94.4%) SO 1/6 PVR, 5/6 PPV + 12/12 (100%), 1.3 Sx per SO eye after initial SB 3/10 PVR, 2/10 PPV 39/39 (100%), 1.22 Sx + SO among eyes reoperated — 3/3 (100%), no second operation
The total number of eyes does not match 104 eyes because some eyes with several associated conditions. Primary reattachment rate not statistically significant between myopic and high myopic eyes (P = 1.000). *One attached in oil. †Two attached in oil. ‡Cataracts treated by lensectomy (two eyes), phacoemulsification combined with glaucoma surgery (one eye). PPV, pars plana vitrectomy; Sx, surgeries.
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Table 5. Intraoperative Clinical Characteristics (Break Type) in 104 Pediatric Cases and Anatomical Outcomes (Reoperation) After Retinal Detachment Surgery n (Eyes)
Type of Break
Primary Reattachment Rate
Dialysis
56*
46/56 (82%)
Round holes
38*
26/38 (68.4%)
HST Unseen breaks or suspicious breaks
7 7
2/7 (28.6%) 4/7 (57%)
Final Reattachment 3+ Rate PPV at Second Operation Operations 54/56 (96.4%)† 35/38† (92%) 7/7† (100%) 5/7 (71%)**
PPV‡ (2/10), SO (2/10), SB (8/10) PPV‡ (5/12), SO (4/12), SB (3/12) PPV‡ (4/5), SO (4/5) PPV (2/3)††, SO (1/3)
0 3§ 1 1
*Two eyes: dialysis + round hole, two eyes: dialysis + HST. †Two eyes with retina attached under SO at the end of follow-up considered as detached. ‡PPV, SO because scleral rupture during SB for RRD recurrence. §Two eyes had three operations to reattach the retina (·1 SB then ·1 PPV with SO or gas), one eye had five operations: ·1 PPV + encirclement and SO, followed by ·3 surgeries by PPV and SO). † **One eye had no further treatment after SB as the first operation due to PVR. ††Two eyes had a reoperation by PPV. Two eyes had recurrence of RRD but no further surgery. HST, horseshoe tear; PPV, pars plana vitrectomy; SO, Silicone oil.
horseshoe tears closed with primary SB, and 4 of 5 eyes needed vitrectomy as a secondary procedure. The final reattachment rate ranged between 92% and 100% depending on the type of break, with the exception of the group presenting with unseen breaks (71%). Effect of age on outcome. Population characteristics and anatomical success rates of SB between 3 different age groups were analyzed: 0 years to 10 years; 11 years to 15 years; 16 years to 18 years (Table 7). Children belonging to the youngest group were most likely to present with an RRD involving the macula (77 vs. 45.3 vs. 50%). As the age increased, there was a trend toward an increase in success rates at either first (70 vs. 76 vs. 85.7%) or second surgery attempt (55.5 vs. 78.6 vs. 100%).
Effect of posterior versus anterior scleral buckling. Posterior equatorial breaks were treated with a wide segmental explant (9 and 11 mm) and comprised 13.6% (14 eyes) of the eyes (Table 8). Anatomical success rates were comparable between this group and the group with more anterior breaks treated with narrower segmental explants (7 mm) (90 eyes); success rate after first surgery was 71% and 73%, respectively (P = 1.000). Complications specific to scleral buckling. Scleral buckling–related complications occurred in seven cases (7%) and included retinal incarceration (two eyes), vertical diplopia and exotropia (three patients), iris incarceration in paracentesis (performed to lower intraocular pressure after suturing explant) in one eye and episcleritis (one eye).
Table 6. Intraoperative Clinical Characteristics in 104 Pediatric Cases, Anatomical Outcomes and Cause of Redetachment After Retinal Detachment Surgery
Type of Break
n (Eyes)
Subgroups
Primary Reattachment Rate
Dialysis
56*
Trauma (27), Myopia (15), (7 .−6 D), Stickler syndrome (1), Down syndrome (1)
46/56 (82%)
Round holes
38*
Myopia (23), (16 .−6 D), trauma (12), Stickler syndrome (6), retinal dystrophy (4), ROP (1) High myopia (2), Stickler syndrome (2), trauma (1), retinal dystrophy (1), Uveitis (1) Myopia (3), 6 .−6 D, Stickler (1), retinal dystrophy (1), after cataract surgery (2)
26/38 (70%)
HST
7
Unseen breaks or suspicious breaks
7
Causes of Redetachment
2/7 (29%)
New break (4), unsupported/faded indent (3), PVR (3) New break (7), faded indent (3), PVR (4) New break (1), PVR (1)
4/7 (57%)
New break (2), PVR (2)
*Two eyes presented dialysis and round hole associated; two eyes presented dialysis and HST associated. In two eyes, the retina remained detached at the end of follow-up. In eyes with round holes, among those who detached two eyes remained detached eventually at the end of follow-up. In eyes with dialysis, among the eyes whose retina redetached, they all went flat eventually. D, diopter; HST, horseshoe tear; ROP, retinopathy of prematurity.
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Table 7. Outcome Versus Age Age Groups
Group I, 0–10, 26 Eyes
Group II, 11–15, 64 Eyes
Group III, 16–18, 14 Eyes
Mean age (years) Predisposing factors
8
13
16.5
Macula off PVR Success rate after first surgery Final success rate Sucess rate at second surgery Use of PPV at second surgery Use of SO
High myopia (8), myopia (1), trauma (10), Stickler (5), retinal dystrophies (2) 77% (20) 3.8% (1) 61.5% (16/26)
High myopia (7), myopia (10), trauma High myopia (1), myopia (4), trauma (5), Stickler (1), other (3): after (23), Stickler (6), others (18): after cataract surgery (1), retinal cataract surgery, retinal dystrophy or dystrophy (2) others 45.3% (29) 50% (7) 11% (7) 14.3% (2) 76% (48/64) 85.7% (12/14)
92.3% (24/26)*
90.6% (58/64)†
100% (15/15)
55.5% (5/9)‡
78.6% (12/16)§
100% (2/2)
66% (6/9)
35.7% (5/14)
100% (2/2)
6/6
3/5
2/2
*One detached, one attached in SO, one detached in SO macula on. †One attached in SO. ‡Nine reoperated. §Fourteen reoperated. PPV, pars plana vitrectomy; SO, silicone oil.
Two cases of scleral rupture occurred during indentation to mark the breaks or because of a deep suture, with one case requiring further vitrectomy. Vertical diplopia induced by segmental SB occurred in two patients, with one resolving while the other
required strabismus surgery. Surgical repositioning was performed for the iris incarceration occurring during anterior chamber paracentesis. There were three cases of delayed resorption of subretinal fluid, defined as being present beyond the first postoperative month.
Table 8. Outcomes: Anterior Versus Posterior SB Group 1, Width of Element 9 to 11 mm, 14 Eyes Predisposing factors Dialysis*† Round hole* HST Success rate after first surgery Final success rate Success rate at second surgery Use of vitrectomy at second surgery Use of SO among vitrectomized eyes at second surgery
Group 2, Width of Element 7 mm, 90 Eyes
P
Trauma (6), high myopia (3), Trauma (34), high myopia (23), myopia (15), Stickler myopia (2), Stickler (2) (10), others (3): after cataract surgery, retinal dystrophy 8 48 6 32 1 6 71.4% (10/14) 73.3% (66/90) 1.000 100% (14/14) 75% (3/4)
95.5% (86/90)‡ 65.2% (15/23)
1.000 1.000
0/4§
56.5% (13/23)¶
0.2844
—
84.6% (11/13)
—
*One eye coexistence round hole + dialysis. †One eye coexistence HST + dialysis. ‡Two eyes considered as “attached”. §Four eyes reoperated. ¶One eye (Eye no. 5: the use of vitrectomy SO at second operation because scleral rupture during cryo-buckling at second operation). HST, horseshoe tear; SO, silicone oil.
SCLERAL BUCKLING FOR RETINAL DETACHMENT ERRERA ET AL
In all three cases, the subretinal fluid resolved within 1 year. There were no cases of explant extrusion during the follow-up period.
Discussion Scleral buckling is a common primary intervention for pediatric RRDs, associated with high success and low complication rates.3 In contrast to adults, in whom the liquefied vitreous and tractional forces allow the accumulation of subretinal fluid (20), the vitreous in the pediatric population is usually nonsyneretic. The presence of a horseshoe tear in this population suggests an anomalous vitreous liquefaction, which may develop after trauma23 or in association with genetic vitreoretinopathies and myopia.24 The presence of nonsyneretic vitreous can influence the outcome of SB, by having a tamponading effect on retinal breaks after the relief of vitreous traction by scleral indentation. We describe the anatomical outcomes in 104 eyes of 99 children who underwent SB for RRD. Previous studies have usually used SB with encircling bands, and in this study, encirclement was used in only 17 of 104 eyes (16%) as the primary intervention in this pediatric population; the remainder underwent SB with a segmental explant only. Although the outcomes of RRD in the pediatric population have been previously described, these studies have either combined the results of SB and vitrectomy as a primary intervention3,9,18,19 or collated the outcomes of SB with primarily encirclement alone.10,15,25–27 Our primary anatomical success rate of 73% with SB alone and a final anatomical success rate of 94% are comparable with published outcomes ranging from 83% to 100% using SB alone in pediatric RRD.10,11,15,22,27 As previously reported,10 as the age increased, there was a trend toward an increase in success rates at either the first or second surgery attempt. Our results are also comparable with those studies that combine the final outcomes of both vitrectomy and SB in children (75%–79%).3,18,19 There is strong support for the use of encirclement as the standard primary procedure for pediatric RRDs, with studies such as Wadhwa et al15 (85 eyes) and Ripandelli et al26 (154 eyes) using this modality in 100% and 97% of cases, respectively. In contrast to this, our study used segmental SB in 84% of cases and showed that similar high success rates (74% anatomical success and 95% final reattachment) are achievable without using encirclement in most of them. The advantages of the latter include a less extensive surgical approach and a lower incidence of buckle-related
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complications (change in refractive error, diplopia, choroidal detachments, anterior segment ischemia, and glaucoma).28 Vitrectomy has been suggested as an intervention for more posterior retinal breaks. In our study, subgroups’ analysis of anterior (narrow segmental explants, 7 mm) versus posterior (wider segmental explant, 9 and 11 mm) type of segmental SB showed no difference in anatomical success rates after first surgery (73 vs. 73%) and in final success rate (95.5 vs. 100%). Our study highlights that segmental SB with a wider explant could offer an effective alternative to vitrectomy in this cohort of patients. Predisposing factors were identified in 62.5% of our cases, comparable with other similar studies.9,10,15,18 Myopia (44%) and trauma (38.5%) were most common, with primary reattachment rates of 59.5% and 80%, respectively. Of note, there was no statistically significant difference in outcomes between myopia and high myopia (.−6 D). In our series, round holes were more commonly seen in myopic children as reported by other authors.3 Interestingly, the majority of cases developing PVR occurred in this group (58% of PVR overall) accounting for the majority of failures. We found that only 48% of patients with dialysis had a history of trauma. The high incidence of retinal dialyses in the absence of reported trauma has been noted by other authors, although the precipitating event may be unreported because of the age of the patient.26 The primary success rate of SB for RRD secondary to dialysis (82%) and round holes (68.4%) was better than those because of horseshoe tears (28.57%) or when no breaks were detected preoperatively (57%). The presence of horseshoe tears in the pediatric population is highly unusual, and as mentioned earlier, may reflect an abnormal etiology (e.g., genetic vitreoretinopathies) with consequent lower success rates. Similarly in this study, factors that increased the level of complexity, such as multiple retinal breaks and more extensive RRDs, are associated with higher risks of redetachments. Our patients with Stickler syndrome had the lowest success rate (50%), consistent with the findings by Chen et al4 that patients with congenital abnormalities have a lower success rate with SB. This reduced success rate may reflect the anomalous nature of the vitreous in this condition, necessitating either encirclement or vitrectomy. As success in segmental SB depends on a sitespecific treatment effect, it is understandable that retinal breaks not identified preoperatively were the most frequent causes of retinal redetachment after the first operation (12 eyes). Remaining failures were
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accounted for by PVR in 10 eyes and inadequate indent support in 6 eyes—premature fading of the buckle in 4 eyes, and the presence of unsupported breaks in 2 eyes. Scleral buckling was performed as a secondary procedure in 51.8% of cases, most commonly when the etiology was trauma (36%) or myopia (27%) or unknown (27%). This achieved reattachment in 85.7% of cases with similar success rates for both segmental and encircling elements. Vitrectomy using either gas or oil was the secondary intervention in 48.2% of cases, most commonly when the etiology was myopia (61%). This modality achieved reattachment in only 54% of cases. The trend toward a lower rate may be attributed to the more complex case mix of eyes undergoing vitrectomy. This study shows that SB is an effective primary intervention in pediatric RRDs, associated with a primary anatomical success rate of 73% after 1 operation and a final reattachment rate of 94%. In contrast to much of the published literature on this subject, the majority of SB procedures used a segmental explant (84%) as opposed to encirclement. As such, the results from this study reassure in proposing segmental SB as a primary intervention for pediatric RRD. This study has highlighted risk factors that reduce the success rates in this specific modality of segmental SB: no breaks identified preoperatively; horseshoe tears; multiple retinal breaks; more than three quadrants of RRD; and Stickler syndrome. Cases presenting with these factors would benefit from either SB using encirclement or pars plana vitrectomy. If the cases with these risk factors are excluded from our analysis (resulting in 40 cases in total), segmental SB results in a primary anatomical success rate of 93% after 1 operation and a final reattachment rate of 95%. In conclusion, this study on primary SB for pediatric RRD in 104 cases shows results comparable with the published literature, with a primary and final anatomical success rate of 73% and 94%, respectively. This confirms that SB represents an excellent choice as a first-line treatment in pediatric RRDs. Of note, this study also highlights the successful use of segmental SB as a viable alternative to SB with encirclement or vitrectomy in selected cases with localized pathology. Key words: retinal detachment, pediatric, scleral buckling. Acknowledgments The authors thank Mr. Paul Sullivan, Vitreoretinal Consultant in Moorfields Eye Hospital, for his help in revising the article.
2015 VOLUME 35 NUMBER 7
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