Surgical Techniques
and Reattachment Rates in Retinal Detachment due to Macular Hole Shoji Kuriyama, MD; Miyo Matsumura, MD; Takafumi Harada, MD; Hitoshi Ishigooka, MD; Nobuchiki Ogino, MD \s=b\ We evaluated reattachment rates of the transvitreal and transscleral techniques for treating 250 eyes with retinal detachment due to macular hole. The initial success rate of the transvitreal approach was 56% (53/94). There was no difference between the results of gas tamponade alone and vitrectomy and gas tamponade. The initial success rate of the transscleral approach was 83% (130/156). Macular diathermy and macular buckling showed a higher reattachment rate than macular diathermy alone. The final success rates were the same (95%), regardless of which approach was selected as an initial technique. The patients whose initial transvitreal reattachment failed and who underwent additional transvitreal procedures (including macular laser photocoagulation) showed a success rate of 93%. We believe that gas tamponade, which has possibility of better visual prognosis, should be selected as an initial technique because the final success rate was found to be the same regardless of the initial surgical
techniques.
(Arch 1561)
Ophthalmol.
1990; 108:1559-
O urgical techniques for treating retinal detachment due to macular hole have changed over the last decade. In 1982, Gonvers and Machemer1 de¬ scribed
a new technique that involved vitrectomy and gas tamponade. Subse¬ quently, some new techniques were investigated by Miyake2 (subretinal fluid drainage and gas tamponade) and Biodi and Folks (paracentesis and gas tamponade). Consequently, the trans-
Accepted for publication June 6, 1990. From the Department of Ophthalmology, Kyoto (Japan) University Faculty of Medicine. Reprint requests to Department of Ophthalmology, Kyoto University Faculty of Medicine, Kyoto 606, Japan (Dr Kuriyama).
vitreal approach has become important in the treatment of retinal detachment due to macular hole, along with the transscleral approach, which includes macular coagulation and macular buck¬ ling. At present, we select a single technique or a combination of two or three from among many techniques based on the success rate, visual prog¬ nosis, technical difficulty, complication frequency, and preoperative and post¬ operative care. Among these factors, success rate is the most important. Recently, there have been numerous reports on the surgical treatment of retinal detachment with macular hole using the transvitreal approach.4"12 However, there seem to be few re¬ ports in which the success rates of many operation techniques13 are com¬ pared. The success rate and visual prognosis of each surgical technique need to be evaluated, and a proper plan needs to be made to treat retinal detachment due to macular hole. In our study, we focused on the success rate. MATERIALS AND METHODS Between 1976 and 1988, 261 eyes of 258 patients (49 men, 209 women; 19 aphakic; all with high myopia) with retinal detach¬ ment due to macular holes but without
peripheral retinal breaks, treated at Kyoto (Japan) University, were reviewed. The surgical techniques employed included the
following:
1. Transvitreal approach: gas tamponade alone (34 eyes); gas tamponade and equato¬ rial scierai buckling (six eyes); gas tampon¬ ade and laser photocoagulation (eight eyes); vitrectomy and gas tamponade (36 eyes); vitrectomy, gas tamponade, and equatorial scierai buckling (10 eyes). 2. Transscleral approach: macular dia¬ thermy and equatorial scierai buckling (36 eyes); macular buckling and equatorial scierai buckling (three eyes); macular dia-
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/12/2015
thermy, macular buckling, and equatorial scierai buckling (118 eyes). In most cases, using the transscleral ap¬ proach, equatorial scierai buckling (encir¬ cling, fixing silicone sponge, scierai infold¬ ing, and scierai resection) was combined with each surgical technique. Cases in which both the transvitreal and transscleral approaches were initially per¬ formed were excluded from the evaluation. Eventually, 250 eyes were evaluated. An initial success is a case in which the initial operation achieved complete reattachment. A final success is a case in which complete reattachment was achieved by the initial
by subsequent operations operation failed. Reattach¬ ment was judged 6 months after the final operation. Only complete reattachment was judged successful. Operations were performed an average of operation
or
when the initial
1.3 times overall: 1.1 times per eye to achieve final success in initial transscleral cases, and 1.6 times per eye to achieve final success in initial transvitreal cases. Al¬ though some complications (vitreous hem¬ orrhage, cataract, new tear formation, and
proliferative vitreoretinopathy) occurred, we did not evaluate them in this study. Extent of retinal detachment was variable from locally confined detachment to totally
bullous detachment. Until 1983, the transscleral approach was selected as an initial and subsequent tech¬ nique, although there was no apparent reg¬ ulation on which transscleral techniques should be chosen. From 1984 to 1985, vi¬ trectomy was mainly selected as an initial technique. After 1986, gas tamponade was selected as an initial technique except in cases in which vitreal traction to the macula was apparent. There was no clear regula¬ tion on the selection of reoperation tech¬ niques during all the periods.
RESULTS Initial Success Rate
For the transvitreal
1), the initial
success
approach (Table
rate of gas tam¬
ponade alone with air or sulfur hexaflu-
oride
was
59% (20/34) and that of gas
with equatorial scierai 83% (5/6). There was no significant difference between the suc¬ cess rates. The initial success rate of vitrectomy and gas tamponade (fluidgas exchange or gas injection) with equatorial scierai buckling was 50% (18/36). This procedure without equa¬ torial scierai buckling had a success rate of 60% (6/10). There was no appar¬ ent difference between the results of the two techniques. Consequently there was no significant difference be¬ tween the results of gas tamponade alone and vitrectomy and gas tampon¬ ade, and between the results of proce¬ dures with and without equatorial scierai buckling. The overall initial suc¬ cess rate of the transvitreal approach was 56% (53/94). The initial success rates of the tech¬ niques using the transscleral approach (Table 1) were as follows: macular dia¬ thermy, 75% (27/36); macular buckling, 100% (3/3); and macular diathermy and macular buckling, 86% (101/118). The total initial success rate was 83% (130/156). There was a significant dif¬ ference in the success rates between macular diathermy alone and macular diathermy and macular buckling (P
and Reattachment Rates in Retinal Detachment due to Macular Hole Shoji Kuriyama, MD; Miyo Matsumura, MD; Takafumi Harada, MD; Hitoshi Ishigooka, MD; Nobuchiki Ogino, MD \s=b\ We evaluated reattachment rates of the transvitreal and transscleral techniques for treating 250 eyes with retinal detachment due to macular hole. The initial success rate of the transvitreal approach was 56% (53/94). There was no difference between the results of gas tamponade alone and vitrectomy and gas tamponade. The initial success rate of the transscleral approach was 83% (130/156). Macular diathermy and macular buckling showed a higher reattachment rate than macular diathermy alone. The final success rates were the same (95%), regardless of which approach was selected as an initial technique. The patients whose initial transvitreal reattachment failed and who underwent additional transvitreal procedures (including macular laser photocoagulation) showed a success rate of 93%. We believe that gas tamponade, which has possibility of better visual prognosis, should be selected as an initial technique because the final success rate was found to be the same regardless of the initial surgical
techniques.
(Arch 1561)
Ophthalmol.
1990; 108:1559-
O urgical techniques for treating retinal detachment due to macular hole have changed over the last decade. In 1982, Gonvers and Machemer1 de¬ scribed
a new technique that involved vitrectomy and gas tamponade. Subse¬ quently, some new techniques were investigated by Miyake2 (subretinal fluid drainage and gas tamponade) and Biodi and Folks (paracentesis and gas tamponade). Consequently, the trans-
Accepted for publication June 6, 1990. From the Department of Ophthalmology, Kyoto (Japan) University Faculty of Medicine. Reprint requests to Department of Ophthalmology, Kyoto University Faculty of Medicine, Kyoto 606, Japan (Dr Kuriyama).
vitreal approach has become important in the treatment of retinal detachment due to macular hole, along with the transscleral approach, which includes macular coagulation and macular buck¬ ling. At present, we select a single technique or a combination of two or three from among many techniques based on the success rate, visual prog¬ nosis, technical difficulty, complication frequency, and preoperative and post¬ operative care. Among these factors, success rate is the most important. Recently, there have been numerous reports on the surgical treatment of retinal detachment with macular hole using the transvitreal approach.4"12 However, there seem to be few re¬ ports in which the success rates of many operation techniques13 are com¬ pared. The success rate and visual prognosis of each surgical technique need to be evaluated, and a proper plan needs to be made to treat retinal detachment due to macular hole. In our study, we focused on the success rate. MATERIALS AND METHODS Between 1976 and 1988, 261 eyes of 258 patients (49 men, 209 women; 19 aphakic; all with high myopia) with retinal detach¬ ment due to macular holes but without
peripheral retinal breaks, treated at Kyoto (Japan) University, were reviewed. The surgical techniques employed included the
following:
1. Transvitreal approach: gas tamponade alone (34 eyes); gas tamponade and equato¬ rial scierai buckling (six eyes); gas tampon¬ ade and laser photocoagulation (eight eyes); vitrectomy and gas tamponade (36 eyes); vitrectomy, gas tamponade, and equatorial scierai buckling (10 eyes). 2. Transscleral approach: macular dia¬ thermy and equatorial scierai buckling (36 eyes); macular buckling and equatorial scierai buckling (three eyes); macular dia-
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/12/2015
thermy, macular buckling, and equatorial scierai buckling (118 eyes). In most cases, using the transscleral ap¬ proach, equatorial scierai buckling (encir¬ cling, fixing silicone sponge, scierai infold¬ ing, and scierai resection) was combined with each surgical technique. Cases in which both the transvitreal and transscleral approaches were initially per¬ formed were excluded from the evaluation. Eventually, 250 eyes were evaluated. An initial success is a case in which the initial operation achieved complete reattachment. A final success is a case in which complete reattachment was achieved by the initial
by subsequent operations operation failed. Reattach¬ ment was judged 6 months after the final operation. Only complete reattachment was judged successful. Operations were performed an average of operation
or
when the initial
1.3 times overall: 1.1 times per eye to achieve final success in initial transscleral cases, and 1.6 times per eye to achieve final success in initial transvitreal cases. Al¬ though some complications (vitreous hem¬ orrhage, cataract, new tear formation, and
proliferative vitreoretinopathy) occurred, we did not evaluate them in this study. Extent of retinal detachment was variable from locally confined detachment to totally
bullous detachment. Until 1983, the transscleral approach was selected as an initial and subsequent tech¬ nique, although there was no apparent reg¬ ulation on which transscleral techniques should be chosen. From 1984 to 1985, vi¬ trectomy was mainly selected as an initial technique. After 1986, gas tamponade was selected as an initial technique except in cases in which vitreal traction to the macula was apparent. There was no clear regula¬ tion on the selection of reoperation tech¬ niques during all the periods.
RESULTS Initial Success Rate
For the transvitreal
1), the initial
success
approach (Table
rate of gas tam¬
ponade alone with air or sulfur hexaflu-
oride
was
59% (20/34) and that of gas
with equatorial scierai 83% (5/6). There was no significant difference between the suc¬ cess rates. The initial success rate of vitrectomy and gas tamponade (fluidgas exchange or gas injection) with equatorial scierai buckling was 50% (18/36). This procedure without equa¬ torial scierai buckling had a success rate of 60% (6/10). There was no appar¬ ent difference between the results of the two techniques. Consequently there was no significant difference be¬ tween the results of gas tamponade alone and vitrectomy and gas tampon¬ ade, and between the results of proce¬ dures with and without equatorial scierai buckling. The overall initial suc¬ cess rate of the transvitreal approach was 56% (53/94). The initial success rates of the tech¬ niques using the transscleral approach (Table 1) were as follows: macular dia¬ thermy, 75% (27/36); macular buckling, 100% (3/3); and macular diathermy and macular buckling, 86% (101/118). The total initial success rate was 83% (130/156). There was a significant dif¬ ference in the success rates between macular diathermy alone and macular diathermy and macular buckling (P
