Current Eye Research, 2014; 39(2): 204–211 ! Informa Healthcare USA, Inc. ISSN: 0271-3683 print / 1460-2202 online DOI: 10.3109/02713683.2013.838270

ORIGINAL ARTICLE

Scleral Buckling and Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment: An Analysis of 542 Eyes

1

Department of Ophthalmology, 2Kitasato Clinical Research Center, and 3Department of Preventive Medicine, University of Kitasato School of Medicine, Kanagawa, Japan

ABSTRACT Purpose: To investigate the anatomical success rates of scleral buckling (SB) and pars plana vitrectomy (PPV) performed for rhegmatogenous retinal detachment (RRD) in a large case series and to identify prognostic factors for the primary anatomical success rates of surgical techniques. Methods: We reviewed 542 consecutive eyes for primary RRD in this retrospective study. Follow-ups were performed for at least six months. In each of the two groups, 271 eyes were examined. The main outcome measure was the primary anatomical success rate. Multivariate analysis was also performed to determine whether independent risk factors of the preoperative parameters for redetachment exist. Results: The primary anatomical success rates were 93.7% and 96.3% in the SB and PPV groups; and the final anatomical success rates were 100% in both groups (each with 271 eyes). In the SB group, eyes with macula-off had significantly lower primary anatomical success rates than those with macula-on (p = 0.002). Preoperative break location or lens status had no significant effect on primary anatomical success rates in either group. Multivariate logistic regression analysis using four variables, namely, sex, posterior vitreous detachment, macular status and preoperative visual acuity, showed that the macular status was an independent risk factor for redetachment in the SB group (p = 0.039, odds ratio 3.7). The six-month follow-up visual acuity was significantly better than the preoperative visual acuity in both groups (p  0.001). Conclusions: Both SB and PPV gave excellent primary and final anatomical success rates. The macula-off status was associated with a lower success rate in the SB group, although break location and lens status had no significant effect on success rates in either group. Keywords: Large case series, pars plana vitrectomy, primary anatomical success rate, rhegmatogenous retinal detachment, scleral buckling

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Hidenaga Kobashi1, Masahiko Takano1, Tomohiko Yanagita1, Tetsu Shiratani1, Guoqin Wang2, Keika Hoshi3 and Kimiya Shimizu1

INTRODUCTION

investigated for the repair of RRD, but has shown a high incidence of failure.3 Many studies have assessed the anatomical success rates in SB and PPV surgeries.1,2,4–8 However, there have been only a few large-scale studies with these success rates.7,8 Moreover, it has not been fully elucidated whether the preoperative characteristics have any impact on primary anatomical success rates

Several surgical techniques have been used successfully in the past to repair rhegmatogenous retinal detachment (RRD). Scleral buckling (SB) and pars plana vitrectomy (PPV) are the most commonly used procedures because of their high anatomical success rates both over 90%.1,2 Pneumatic retinopexy has been

Received 26 March 2013; revised 23 July 2013; accepted 21 August 2013; published online 21 October 2013 Correspondence: Hidenaga Kobashi, MD, PhD, Department of Ophthalmology, University of Kitasato School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 228-8555, Japan. Tel: +81-42-778-9012. Fax: +81-42-778-9920. E-mail: [email protected]

204

Success Rates of Retinal Detachment with either technique. The purpose of this study is to retrospectively assess the anatomical success rates of SB and PPV performed for RRD in a large case series. We also tried to identify prognostic factors for primary success in both surgical techniques and the preoperative characteristics.

MATERIALS AND METHODS

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Patients Five hundred forty-two eyes of 526 consecutive patients (359 eyes of 347 men and 183 eyes of 179 women) were included retrospectively in this study. Inclusion criteria were primary RRD, SB and PPV as the primary procedures, and a follow-up period of at least 6 months. Patients with a retinal detachment resulting from macular breaks, giant retinal tears or ocular trauma, use of silicone oil in the first surgery, or with complications such as retinopathy of prematurity or severe proliferative vitreoretinopathy (PVR) of grade C2 or greater, were excluded from this study. Diagnosis of PVR was determined by the type of retinal detachment.9 In all cases, the surgery was performed by one of two surgeons (M. T. and T. Y.) at Kitasato University Hospital, Kanagawa, Japan.

Surgical Indications Informed consent was obtained from all patients before surgery. All underwent slit-lamp examinations including biomicroscopy of the vitreous and the retina and indirect ophthalmoscopy. All eyes without a completely detached posterior vitreous were treated by SB. In each eye whose posterior vitreous was completely detached, the choice of SB or PPV was based on the relevant surgeon’s preoperative examination. Complete posterior vitreous detachment (PVD) was diagnosed by a slit-lamp examination with a þ90 diopter aspheric lens, and a sheet-like structure, the ascension phenomenon, the whiplash phenomenon10 and a glial ring were taken as positive signs. Almost all the pseudophakic patients with RRD underwent PPV. The eyes with RRD were divided into those with the SB group (n = 271) and those with the PPV group (n = 271).

Surgical Techniques SB consisted of implant and explant procedures, which were performed on 157 eyes and 114 eyes, respectively. The technique of implant buckling used was similar to that described previously by Schepens et al.11 In implant surgery, all rectus oculi muscles were tagged !

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with silk sutures. After localization of the retinal breaks and the extent of detachment, scleral dissection was performed and buckle was sited based on the extent of the detachment. Silicone tires (Mira No. 276, MIRA, Waltham, MA) were sited at the scleral flap, which was treated with diathermy, and an encircling silicone band (Mira No. 240) was applied. In explant surgery, following localization of the original retinal breaks, cryopexy was performed for the retinal tear. Circumferential or radial buckles were sutured using silicone sponges (Mira No. 504, 505, 506 and 507). In the SB group, some patients underwent subretinal fluid drainage when large amounts of fluid remained over the buckle. If necessary, after the draining of subretinal fluid, air was injected as intravitreal gas to prevent ocular hypotension. In the PPV group, PPV combined with cataract surgery for phakia was performed in 228 eyes to facilitate peripheral vitrectomy and to prevent postoperative cataract progression in the lens; primary vitrectomy was performed in 42 eyes for pseudophakia and in one eye for aphakia. In PPV combined with cataract surgery, an acrylic lens was implanted through a 3-mm self-sealing corneoscleral incision in the combined cataract surgery. A standard 20-gauge three-port PPV was performed at 1500 cuts/min. To identify all existing retinal breaks and release all vitreoretinal traction around the retinal breaks, we extended the vitrectomy to the vitreous base, while maintaining posterior scleral depression following a core vitrectomy. As necessary, the peripheral vitreous was visualized using triamcinolone acetonide in order to make it easy to cut. Subretinal fluid was drained through the original retinal breaks in most cases and, if necessary, through a posterior retinotomy site in eyes with anterior retinal breaks. All retinal breaks and drainage retinotomy sites were sealed with endolaser photocoagulation or cryopexy after a fluid–air exchange. The PPV procedure did not include a 360 encircling band or 360 endolaser photocoagulation in the peripheral retina. After the wound was closed, 20% of sulfur hexafluoride was used for internal tamponade. Patients were instructed to remain in the facedown position until the volume of intravitreal gas decreased to less than 40% of that of the vitreous cavity.

Statistical Analysis All statistical analyses were performed using SPSS software version 15.0 (Statistical Package for Social Science Incorporated [SPSS], Inc., Chicago, IL). The results are expressed as mean  standard deviation or n (%). The data were analyzed with Fisher’s exact test for categorical variables, and the Mann–Whitney U test for continuous variables. Multivariate analysis was performed to determine independent risk factors of preoperative parameters for redetachment.

206 H. Kobashi et al. Variables with a p value 50.15 in univariate analysis were entered into a logistic regression model. A p value 50.05 was considered statistically significant. A six-month postoperative best-corrected visual acuity (BCVA) was compared with the preoperative BCVA using the paired t-test. Measured decimal visual acuities were converted to logarithms of the minimum angles of resolution (logMAR) for subsequent analysis. Visual acuities for finger counting, hand motions and light perception were assigned logMAR values of 2.0, 3.0 and 3.3, respectively.12

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RESULTS Patient Characteristics Table 1 shows the preoperative characteristics of both groups of patients. SB was performed on 271 eyes of 259 patients. The mean age was 43.3  17.5 years (range 12–85 years). PPV was also performed on 271 eyes of 267 patients. The mean age was 58.0  8.7 years (range 26–80 years). The two groups were significantly different in most variables that might have an influence on surgical outcome.

operation without additional surgery, was achieved in 254 of 271 eyes (93.7%) in the SB group and in 261 of 271 eyes (96.3%) in the PPV group; final anatomical success, defined as retinal attachment within six months of follow-up without regard to additional procedures, was achieved in all the eyes in both groups. To identify other variables associated with the primary anatomical success rates, we analyzed the primary anatomical success rates in preoperative status subgroups (Table 2). In the SB group, analysis of the primary anatomical success rates showed a significant difference between the macula-off and macula-on subgroups (p = 0.002), but no such difference when the inferior break subgroup and the superior break subgroup were compared in either the SB or the PPV group, although eyes with superior breaks had slightly better results than eyes with inferior breaks in the PPV group (p = 0.210). In the SB group, the extent of detachment was 3.3  0.5 quadrants and 1.6  0.6 quadrants in eyes with macula-off and macula-on subgroups, respectively (p50.001). Lens status had no significant effect on primary anatomical success rates in either group (p = 0.999).

Multivariate Analysis Anatomical Outcomes The primary anatomical success, defined as retinal reattachment within six months after a single

The results of the univariate logistic regression analyses for the preoperative characteristics are shown in Table 3. Multivariate logistic regression

TABLE 1 Preoperative characteristics of patients in SB and PPV. SB (n = 271) No. of patients No. of men (%) Mean age  SD, (y) Complete PVD, n (%) Macula-off, n (%) Status of PVR, n (%) Absent Grade A/B Grade C1 Type of break, n (%) Tear Hole Both No. breaks (range) Median Inferior breaks, n (%) Undetected break, n (%) Vitreous hemorrhage, n (%) Extent of detachment (quadrants) Preoperative lens status Phakia, n (%) Pseudophakia, n (%) Aphakia, n (%)

PPV (n = 271)

p Value

259 168 (62.0) 43.3  17.5 148 (54.6) 91 (33.6)

267 191 (70.5) 58.0  8.7 271 (100) 136 (50.2)

171 (63.1) 97 (35.8) 3 (1.1)

162 (59.8) 104 (38.4) 5 (1.8)

143 (52.8) 82 (30.3) 46 (16.9) 2.2  1.7 (1–12) 1.9 102 (37.6) 5 (1.8) 4 (1.5) 2.2  0.8

223 (82.3) 23 (8.5) 25 (9.2) 2.3  1.8 (1–15) 2.0 44 (16.2) 8 (3.0) 24 (8.9) 2.7  2.0

50.001a

260 (95.9) 8 (3.0) 3 (1.1)

228 (84.1) 42 (15.5) 1 (0.4)

50.001a

0.046a 50.001b 50.001a 50.001a 0.480

0.453 50.001a 0.576 50.001a 50.001b

SB = scleral buckling, PPV = pars plana vitrectomy, SD = standard deviation, y = years and PVD = posterior vitreous detachment. a Statistically significant (Fisher’s exact test). b Statistically significant (Mann–Whitney U test). Current Eye Research

!

0.999 0.999 100% (11/11) 97.7% (42/43)

Complications

SB = scleral buckling and PPV = pars plana vitrectomy. *Pseudophakic subgroup includes three aphakic eyes and one aphakic eye in the SB and PPV groups, respectively. yStatistically significant (Fisher’s exact test).

0.799 0.210 94.1% (159/169) 96.9% (222/227) 93.1% (95/102) 93.2% (41/44) 0.002y 0.749 97.2% (175/180) 97.0% (131/135) 86.8% (79/91) 95.6% (130/136) 93.7% (254/271) 96.3% (261/271) SB PPV

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analysis using four variables, namely, sex, PVD, macular status and preoperative BCVA, showed that the macular status was an independent risk factor for redetachment in the SB group (p = 0.039, odds ratio 3.7).

93.5% (243/260) 96.1% (219/228)

p Value Pseudophakic* Superior breaks Inferior breaks Macula-on Macula-off Total

Macular status subgroups

TABLE 2 Primary anatomical success rates in the two groups.

p Value

Break location status subgroup

p Value

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Phakic

Lens status subgroups

Success Rates of Retinal Detachment

The eyes in which redetachment occurred after primary surgery and surgical complications are shown in Table 4. Seventeen eyes (6.3%) in the SB group and 10 eyes (3.7%) in the PPV group developed retinal redetachment within a six-month period after primary surgery. The average number of operations in the SB and PPV groups within a six-month period were 1.08 and 1.06, respectively. In both groups, there were few intraoperative or postoperative complications. The most common cause of retinal redetachment was the reopening of an original break in the retina (SB group, 8 eyes and PPV group, 6 eyes). The cause of reopened breaks was mainly associated with an incomplete buckling position in the SB group and incomplete cutting of the vitreous in the PPV group. PVR developed in one eye (0.4%) after primary surgery in each group.

Visual Acuity The preoperative and six-month follow-up BCVA results were divided into subgroups and are shown in Table 5. Overall, the mean BCVA was found to be significantly improved at the six-month follow-up visits as compared with the preoperative visits in both SB and PPV groups (p  0.001 in both groups). In the SB group, a similarly significant improvement was seen in the phakic and macula-off subgroups; however, those eyes with pseudophakia or macula-on detachments showed no significant change in BCVA. In the PPV group, the mean BCVA also improved significantly in the phakic, pseudophakic, macula-off and macula-on subgroups. It should be noted that PPV, which was performed in all 228 phakic eyes, was combined with cataract surgery in order to prevent the development of a cataract.

DISCUSSION Our study indicated that single procedure success rates were over 90% in both SB and PPV groups. Following a second operation, our final anatomical success rate of 100% in both treatment groups was similar to those in previous studies. As detailed in Table 6, these success rates compare favorably with previously published anatomical outcomes for SB or PPV in consecutive RRD. Our primary success rates

208 H. Kobashi et al. TABLE 3 Analysis of risk factors for redetachment in both techniques. p Value in univariate analysis Variable

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Sex Age PVD Macula-off status Lens status No. of breaks Extent of detachment Location breaks and detachment Vitreous hemorrhage Preoperative BCVA Combined cataract surgery

SB (OR, 95% CI) 0.077 0.220 0.145 0.004 0.999 0.537 0.549 0.999 0.999 0.053

(3.3, 1.05–14.40) (1.0, 0.99–1.05) (2.3, 0.83–7.25) (4.4, 1.65–13.04) (NA) (1.0, 0.69–1.26) (1.0, 0.52–1.86) (1.1, 0.37–2.78) (NA) (2.2, 1.10–4.00) NA

p Value in multivariate analysis

PPV (OR, 95% CI)

SB (OR, 95% CI)

PPV (OR, 95% CI)

0.999 (1.0, 0.22–3.79) 0.669 (1.0, 0.91–1.05) NA 0.749 (1.5, 0.42–6.03) 0.999 (1.7, 0.31–32.20) 0.587 (1.1, 0.76–1.39) 0.923 (0.9, 0.37–1.17) 0.210 (2.3, 0.48–8.65) 0.608 (NA) 0.076 (2.0, 0.99–3.88) 0.999 (0.58, 0.03–3.21)

0.059 (3.1, 0.96–13.95) NE 0.075 (2.6, 0.91–8.59) 0.039 (3.7, 1.06–13.45) NE NE NE NE NE 0.579 (1.3, 0.50–2.85) NA

NE NE NA NE NE NE NE NE NE 0.053 (2.0, 0.99–3.88) NE

SB = scleral buckling, PPV = pars plana vitrectomy, OR = odds ratio, CI = confidence interval, PVD = posterior vitreous detachment, BCVA = best-corrected visual acuity, NA = not available and NE = not entered into multivariable analysis.

TABLE 4 Redetachment and surgical complications in the two groups.

Redetachment after primary surgery, n (%) Mean time (mos) from primary to secondary surgery Median (mos) Average number of operations Intraoperative complication Iatrogenic retinal break, n (%) Needle perforation, n (%) Postoperative complication Reopening of an original break, n (%) New break required for reoperation, n (%) PVR, n (%) Macular pucker, n (%) Cystoid macular edema, n (%) Choroidal detachment, n (%) Transient diplopia, n (%) Posterior synechia of iris, n (%) Pupillary block, n (%)

TABLE 5 Visual acuity outcomes in the two groups. Preoperative BCVA (logMAR)

6-month BCVA (logMAR)

p Value

SB Total (n = 271) Phakic (n = 260) Pseudophakic (n = 11) Macula-off (n = 91) Macula-on (n = 180)

0.29 0.25 1.21 0.79 0.04

0.13 0.11 0.62 0.36 0.02

0.001a 0.002a 0.154 50.001a 0.171

3 (1.1)

PPV Total (n = 271) Phakic (n = 228) Pseudophakic (n = 42) Macula-off (n = 135) Macula-on (n = 136)

0.68 0.69 0.62 1.14 0.21

0.14 0.13 0.21 0.25 0.03

50.001a 50.001a 0.042a 50.001a 50.001a

1 (0.4) 1 (0.4) 2 (0.7)

1 (0.4) 2 (0.7) 1 (0.4)

SB = scleral buckling, PPV = pars plana BCVA = best-corrected visual acuity. a Statistically significant (paired t-test).

2 (0.7) 2 (0.7) 0

0 0 3 (1.1)

SB (n = 271)

PPV (n = 271)

17 (6.3)

10 (3.7)

2.3  2.0

1.2  1.1

0.7 1.08

0.4 1.06

1 (0.4) 1 (0.4)

21 (7.7) 0

8 (3.0)

6 (2.2)

5 (1.8)

0

3 (1.1)

SB = scleral buckling, PPV = pars plana vitrectomy, PVR = proliferative vitreoretinopathy and mos = months.

after SB and PPV were superior to those obtained in previous large-scale studies.7,8 However, we did not completely match preoperative characteristics in the patient backgrounds. The success rates were thought to be influenced mainly by preoperative characteristics or surgeon’s preference. We consider that this study is not clinically acceptable for comparison of the anatomical outcomes of the two surgical techniques. Some surgeons used adjuvant SB, prophylactic 360 endolaser photocoagulation and routine perfluorocarbon liquid in PPV.1,4,8 However, in our cases, we did not use adjunctive SB or 360 of endolaser. Several reports showed that it was not necessary to combine

vitrectomy

and

PPV with SB or 360 endolaser photocoagulation in primary RRD surgeries, although these prior reports covered much smaller patient numbers.13,14 Thus, our PPV group had an excellent anatomical success rate without SB or 360 of endolaser. In the SB group, preoperative posterior vitreous status represented no independent risk factor for redetachment, indicating that PVD had no effect on the primary anatomical success rate. In the PPV group, eyes without complete PVD were not selected. Attempting to induce PVD by PPV intraoperatively in eyes without complete PVD may be difficult and sometimes creates new retinal breaks. Furthermore, unless vitrectomy is performed as completely as possible, the detached retina fails to attach, and this leads to PVR. Therefore, in this study, eyes without complete PVD were enrolled for the SB technique. In addition, accommodation was preserved in these eyes because cataract surgery was not performed simultaneously. On the other hand, if complete PVD is Current Eye Research

Success Rates of Retinal Detachment

209

TABLE 6 Previously published results: anatomical outcomes of SB and PPV for RRD. Anatomical success rate Primary % a

Study (year) 4

Oshima et al. (2000) Miki et al. (2001)1

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Sharma et al. (2005)5 Brazitikos et al. (2005)6 Ahmadieh et al. (2005)7 Heimann et al. (2007)8 Heimann et al. (2007)8 Koriyama et al. (2007)2 Current

n (SB/PPV)

Design

Lens status

Retrospective, two centers Retrospective, single center Prospective, randomized, single center Prospective, randomized, single center Prospective, randomized, multijustify Prospective, randomized, multijustify Prospective, randomized, multijustify Prospective, randomized, single center Retrospective, single center

Phakic, pseudophakic Phakic

55/47

91%

138/87

Pseudophakic

PPV

Incidence of PVR

SB

PPV

91%

100%

100%

3.6%

4.2%

92%

92%

100%

100%

0

3.4%

25/25

76%

84%

100%

100%

20.0%

4.0%

Pseudophakic

75/75

82.7% 94.7% 94.7% 98.7% 5.3%

4.0%

Pseudophakic, aphakic Phakic

126/99

68.2% 62.6% 85%

–

209/207

63.6% 63.8% 96.7% 96.6% 12.4%

16.4%

Pseudophakic

133/132

53.4% 72.0% 93.2% 95.5% 22.6%

15.2%

Phakic

23/23

91%

Phakic, 271/271 pseudophakic, aphakic

SB

Final %

91%

92%

SB

–

PPV

100%

100%

4.3%

8.7%

93.7% 96.3% 100%

100%

0.4%

0.4%

SB = scleral buckling, PPV = pars plana vitrectomy, n = no. of observations, PVR = proliferative vitreoretinopathy. First author.

a

present, tractional forces are minimized because the vitreous is inserted only at the vitreous base but is not anchored posteriorly.15 In our SB group, the primary anatomical success rate was obtained in 86.8% of the macula-off subgroup and in 97.2% of the macula-on subgroups, indicating that the macula-off status was associated with a lower success rate. These findings are in line with those in Thelen et al.16 Macula-off is widely regarded as one of several factors leading to a worse anatomical and functional outcome, together with the extension of the detachment, a history of earlier detachments and advanced age.17 Thus, we believe that macula-off detachments are associated with more severe traction on the pathogenic retinal breaks, and this excess traction is not adequately eliminated by an SB technique. In the macula-off subgroup, there were eight eyes (66.7%) with PVD in among 12 eyes with redetachment after primary SB surgery, suggesting that the eyes with PVD would be so rapidly detached that the macula would also become detached. Especially in eyes with both PVD and macula-off, it may be necessary to consider the choice of PPV. In the PPV group, although eyes with superior breaks had slightly better results than eyes with inferior breaks, the primary anatomical success rate of the repair of RRD did not significantly differ between the inferior and superior breaks, which was in line with Sharma et al.18 On the other hand, Goto et al.19 reported that the anatomical success rate of primary vitrectomy for RRD with inferior breaks was lower than that of RRD with superior breaks (80% versus 98%). The decision to use PPV in combination with SB !

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is often related to the presence of inferior retinal breaks, to supplement the presumably less effective tamponade on the inferior retina.20 Several studies have questioned the need for combined surgery for inferior RRD, but this issue is still under debate.21,22 However, no PPV with SB surgery was included in our study. We found no significant differences in the primary anatomical success rates between phakic and pseudophakic eyes when SB or PPV was performed. However, our pseudophakic eyes fell to this irregular distribution because of selecting PPV. In the PPV group, all phakic eyes were treated by the phacovitrectomy and intraocular lens implantation. Several studies reported that PPV combined with cataract surgery offered significant advantages to both patient and surgeon in the management of RRD.23,24 We believe that phacovitrectomy and intraocular lens implantation is effective and could avoid the difficulties of postvitrectomy cataract surgery.25,26 The most serious complication following retinal detachment surgery is postoperative PVR, which has been reported to occur in 0–23% of patients undergoing SB and in 4–16% of those undergoing PPV; the incidences reported previously were variable (Table 6). In this study, postoperative PVR was confirmed in one eye (0.4%) in each group. We assume that in the PPV group our surgeons attempted to cut completely through the base of the vitreous, thus decreasing the risk of the postoperative occurrence of PVR. Furthermore, we performed PPV without adjunctive SB or 360 of endolaser. Extensive (360 ) endolaser photocoagulation has

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210 H. Kobashi et al. previously been linked to increased rates of PVR after vitrectomy.27,28 For our study, eyes at a high risk of developing PVR had been excluded, and the indication has been expanded to include eyes generally indicated for SB, all of which contributed to lowering the incidence of postoperative PVR. There are two limitations to this study. First, the preoperative characteristics of patients were unbalanced between the SB and PPV groups. Because this was a retrospective study, there were several guidelines for the choice of the surgical approach, and the choice of whether to perform SB or PPV was left to the surgeon’s preference. A further prospective randomized study is needed in order to clarify the prognostic factors for the primary anatomical success rates in both surgical techniques and the preoperative characteristics. Second, in the PPV group, concomitant cataract surgery was performed on all phakic eyes in order to bring about better visual outcomes. Although patients with severe cataracts were not included in this study, we cannot completely exclude the effects of the removal of a cataract on the visual acuity results. In fact, there was significant improvement in visual acuity after PPV combined with cataract surgery in patients with macula-on RRDs. Our results are in line with those reported in patients after phacovitrectomy by Smith et al.23 In conclusion, both SB and PPV surgical techniques were found to yield high anatomic success rates and low complication rates in the treatment of primary RRD. The macula-off status was associated with a lower success rate in the SB group, although break location and lens status had no significant effect on success rates in both groups.

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ACKNOWLEDGEMENTS The authors are grateful to Mr. C. W. P. Reynolds for his careful linguistic assistance with this manuscript.

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DECLARATION OF INTEREST

15.

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

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17.

REFERENCES 1. Miki D, Hida T, Hotta K, Shinoda K, Hirakata A. Comparison of scleral buckling and vitrectomy for retinal detachment resulting from flap tears in superior quadrants. Jpn J Ophthalmol 2001;45:187–191. 2. Koriyama M, Nishimura T, Matsubara T, Taomoto M, Takahashi K, Matsumura M. Prospective study comparing the effectiveness of scleral buckling to vitreous surgery for

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