|Year : 2020 | Volume
| Issue : 9 | Page : 1248-1253
Are outcomes of surgery for retina detachments from giant tears worse than from other holes and tears in this era of small gauge vitrectomy and perflorocarbon use in Sub-Saharan Africa?
O Oderinlo, A Hassan, O Okonkwo, T Bogunjoko, O Idris
Eye Foundation Retina Instituite, Eye Foundation Hospital, GRA Ikeja, Lagos, Nigeria
|Date of Submission||03-May-2020|
|Date of Acceptance||22-May-2020|
|Date of Web Publication||10-Sep-2020|
Dr. O Oderinlo
Eye Foundation Hospital, 27 Isaac John GRA Lagos
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: To report a comparison of clinical features, visual and anatomic outcomes between patients with retinal detachments from giant retinal tears (GRTs) and those from other types of holes and tears undergoing retina reattachment surgery in the same institution within the same time period in sub-Saharan Africa. Materials and Methods: A retrospective noncomparative case series of patients undergoing primary retina detachment (RD) repair for rhegmatogenous retina detachment (RRD) at Eye Foundation Hospital Retina Institute between January 2014 and December 2018 was done. Results: A total of 275 eyes of 275 patients met the inclusion criteria. Ages ranged from 7 to 87 years. And 81 (29.4%) eyes had giant tears were categorized as group A and 194 (70.6%) eyes had other types of tears were categorized as group B. At presentation Visual acuity in 66 eyes (79.6%) in the group A was worse than 3/60, compared to 117 eyes (60.3%) in group B. Primary anatomic success was achieved in 73 eyes (92.4%) in-group A and 157 eyes (86.7%) in group B. Final anatomic success was achieved in 75 eyes (94.9%) in group A and 164 eyes (93.2%) in group B. Good visual outcomes were achieved in 48 eyes (59.3%) in group A and 126 eyes (65.6%) in group B. Conclusion: Good anatomic and visual outcomes can be achieved after surgery for RRD secondary to giant tears in a sub-Saharan Africa setting in this era of small gauge vitrectomy and perflourocarbon use, these outcomes are comparable to those from surgery for RRD secondary to other types of holes and tears.
Keywords: Giant retina tear, perflourocarbon, retinal detachment, rhegmatogenous retinal detachment, scleral buckle, vitrectomy
|How to cite this article:|
Oderinlo O, Hassan A, Okonkwo O, Bogunjoko T, Idris O. Are outcomes of surgery for retina detachments from giant tears worse than from other holes and tears in this era of small gauge vitrectomy and perflorocarbon use in Sub-Saharan Africa?. Niger J Clin Pract 2020;23:1248-53
|How to cite this URL:|
Oderinlo O, Hassan A, Okonkwo O, Bogunjoko T, Idris O. Are outcomes of surgery for retina detachments from giant tears worse than from other holes and tears in this era of small gauge vitrectomy and perflorocarbon use in Sub-Saharan Africa?. Niger J Clin Pract [serial online] 2020 [cited 2020 Sep 27];23:1248-53. Available from: http://www.njcponline.com/text.asp?2020/23/9/1248/294677
| Introduction|| |
A giant retina tear is defined as a full thickness retina tear that extends at least 90° of the retina circumference or 3 clock hours, associated with a detachment of the vitreous Retina detachments (RDs) from giant retina tears usually progress rapidly, the giant tears edges easily roll over and they are often associated with advanced proliferative vitreoretinopathy (PVR). Surgery is thus more technical and traditionally outcomes have been reported poor.,, In order to overcome the peculiar challenges with giant retina tear surgeries, many innovations have been used over the years. Some of these techniques include, intentional retina incarceration, rotating head movements (“steamrolling”) to unfold the tear, and manipulation of the retinal flap using intraocular balloons, tissue adhesives, sodium hyaluronate, and retinal tacks, screws, and sutures.,,,,,, The introduction of the use of perflourocarbon fluids stands out as a major advance in surgery, this has made surgery easier with better outcomes. However, the debate about whether adjunctive procedures, such as scleral buckling, lensectomy, or silicone oil injection are compulsory is still on going. Availability of wide field angle viewing and small gauge vitrectomy also contributes to making surgery technically easier and a more rewarding experience for both the surgeon and patient. Risk factors for developing a GRT include trauma, high myopia, Marfans syndrome, Stickler's syndrome or other hereditary vitreoretinopathies, and extensive lattice degeneration,, Additional etiologies for GRT include iatrogenic and idiopathic causes.
In sub-Saharan Africa, there is a delay in presentation by the patients, a reduced availability of facilities and personnel as well as scarce resources. This could prove to be an additional challenge in management of giant retina tear cases. A number of institutions in the region now have facilities and trained personnel to handle complex RDs including those from giant retina tears. Our study reports our experience with the management of these cases, our preferred surgical technique and choice of intraocular tamponade (silicon oil or gas). We also compare both anatomic and visual outcomes with results of rhegmatogenous detachments from other types of retina holes and tears. Our aim is to report a comparison of outcomes of surgery for rhegmatogenous retina detachment (RRD) between eyes with giant retina tears and those with other types of tears in this era of recent advancements in vitreoretina surgery.
The purpose of this study is to report a comparison of clinical features, visual, and anatomic outcomes between patients with retinal detachments from giant retinal tears (GRTs) and those from other types of holes and tears undergoing retina reattachment surgery in the same institution within the same time period in sub-Saharan Africa.
| Materials and Methods|| |
In accordance with the guidelines from the Declaration of Helsinki, the Institutional Review Board at the Eye Foundation Retina Institute approved this study. A retrospective noncomparative case series of patients undergoing primary RD repair for RRD at Eye Foundation Hospital Retina Institute between January 2014 and December 2018 was done. Patients with a history of retinopathy of prematurity, tractional RDs from diabetic retinopathy, sickle cell retinopathy, choroidal, and exudative RDs and RDs from complications of posterior uveitis were excluded from this study. Data collected included demographic information, recorded etiologies, preoperative VA, duration of detachment, and surgical techniques. Outcome variables that were studied included best-corrected VA, occurrence of single operation retinal reattachment (primary anatomic success, PAS) maintained for a minimum of 3 months as well as at the last clinic visit and anatomic reattachment at last surgery (final anatomic success, FAS) maintained until last clinic visit. A good visual outcome was defined as a best corrected VA of 6/60 and better at least 2 months after surgery maintained until last clinic visit. The surgical technique was at the discretion of the individual surgeon since there was no defined surgical protocol for this study. However, surgery was done with either The Alcon Constellation using 23G or 25G instruments, perflourocarbon fluids were used at the surgeons' discretion for both giant tears and other holes or tears. Data were analyzed in two groups for preoperative factors, surgeries done, anatomic and visual outcomes. Group A is the giant retina tear group and group B the group containing other holes and tears. The data on pre operative PVR were not included in this study as there were inconsistencies in the medical records and lack of standardization in its classification among the surgeons. Surgical variables were analyzed using the Chi-squared test and Student's t-test. All statistical analyses were performed using SPSS version 24.0 (IBM Corporation Armonk, NY, USA)
| Results|| |
A total of 343 patients had retina reattachment surgery for rhegmatogenous retinal detachment (RRD) within the specified study period. Only 275 eyes of 275 patients met the inclusion criteria. Ages ranged from 7 to 87 years. There were 196 (71.2%) males and 79 (23.3%) female patients. 81 (29.4%) eyes had giant tears were categorized as group A and 194 (70.6%) eyes had other types of tears were categorized as group B.
Preoperative characteristics [Table 1]
In the giant tear group (group A) only 7 (9.7%) patients presented early (within a week of onset of RD) compared to 27 (14.8%) patients in the group of other holes group (group B). Most patients presented after a week of diagnosis.
Visual acuity (VA) in 66 eyes (79.6%) in the group A was worse than 3/60, compared to 117 eyes (60.3%) in group B, whereas no eye in group A had VA of 3/60 but worse than 6/60 compared with 15 eyes (7.7%) in group B, 11 eyes (13.6%) had VA of 6/60 but worse than 6/18 in group A, compared to 37 eyes (19.1%) in group B. 4 eyes (4.9%) in-group A had VA of 6/18 and better compared to 25 eyes in-group B. The macula was affected by the RD in 63 eyes (88.7%) in-group A compared to 136 eyes (76.4%) in-group B.
Type of surgery. [Table 2]
Four different types of surgical interventions were done, combined 3 port pars plana vitrectomy (3PPV) with silicon oil exchange and sclera buckling (SB) was done in 12 eyes (14.8%) in group A and 33 eyes (17.0%) in group B, only sclera buckle with or without drainage of subretina fluid was done in no group A eye and 15 eyes (7.7%) in group B, 3PPV with silicon oil exchange was done in 68 eyes (84%) in group A and 138 eyes (71.1%) in group B, 3PPV with gas for tamponade gas was done in 1 eye (1.2%) in group A and 8 eyes (4.1%) in group B.
Anatomic and visual outcome. [Table 3]
PAS was achieved in 73 eyes (92.4%) in group A and 157 eyes (86.7%) in group B. FAS was achieved in 75 eyes (94.9%) in group A, and 164 eyes (93.2%) in group B. Good visual outcomes were achieved in 48 eyes (59.3%) in group A and 126 eyes (65.6%) in group B. None of the differences in primary anatomical success, final anatomical success, and visual outcome between both groups were statistically significant. Using the Pearson Chi-square, test of statistical significance. P values were P = 0.189 for PAS, P = 0.593 for FAS and P = 0.318 for good visual outcomes.
A simple logistic regression was done to show whether eyes having GRTs (group A) were more likely to achieve primary or FAS as well as good visual outcomes. Eyes with GRTs (group A) did not show any statistically significant likelihood achieving PAS, (B = 0.792, OR = 2.207 CI = 0.730-6.669 P = 0.161). Likewise, FAS was not statistically significant for eyes in with giant retina tears (group A) (B = -0.044, OR = 0.957, CI = 0.238–3.853, P = 0.951). Equally the achievement of good visual outcome was not statistically significant between both groups (B = -0.465, OR = 0.628, CI = 0.354-1.115, P = 0.112).
| Discussion|| |
The recent introduction of perflourocarbon fluids in the management of RRDs from giant retina tears has contributed significantly to improved anatomic and visual outcomes. Historic reattachment rates have been very low for these types of detachments, some reports giving values between 6% and 44%. Both primary and FAS rates in our study were quite encouraging for both groups. The giant tear group (group A) had 92.4% PAS compared to in 86.7% in group B with eyes with other types of holes and tears. This showed a higher likelihood for eyes with giant tears to achieve PAS; this finding was however not statistically significant. These encouraging results were obtained despite 88.7% of eyes in the group A and 76.4% in group B presenting with macula off RRD. PAS is comparable between both groups. The likelihood of giant tears to achieve PAS might be related to the extent of the tear, which sometimes might actually mimic a retinectomy coupled with the fact that surgeons preferred to do 360° endolaser for them. The use of perflorocarbon liquids (PFCL) contributed to good anatomic outcomes too. Both surgeons (O.O and O.O) who performed all surgeries on included patients used PFCL routinely for giant tears. The use of smaller gauge vitrectomy, probes with faster cut rates, better duty circles, and wider-angle endo illumination helped to improve outcomes. The Alcon Constellation machine and Zeiss Lumera 700 microscope with Resight 700 lens for posterior segment visualization was used for all surgeries. With these new technology adequate access to peripheral retina for good vitreous shaving and peeling of anterior PVR membranes when present are made possible with better outcomes achieved.
In achieving PAS no scleral buckles were done for giant tears, although some authors report use of scleral buckles for giant tears, we did not consider them the ideal procedure. Giant tears have a tendency to roll over and develop PVR rapidly; hence buckles will likely have higher failure rates than vitrectomies. 84% of eyes in group A had vitrectomy with silicon oil as tamponade compared to 71.1% in group B showing a preference for vitrectomy. A total of 96% of eyes in group A had vitrectomy either alone or combined with a scleral buckle, compared with 92% in group B. Silicon oil was the preferred tamponade in both groups as good outcomes are reported for silicon oil in eyes with complex pathologies., The preference for vitrectomy as a procedure and silicon oil as a tamponade is related to most eyes having complex pathologies, the earlier improvement of vision with silicon was also considered, patients were able to travel back by air and have better acuities on first post operative day when compared with gas. Intraocular gas was not a common tamponade used in both groups as it was utilized in only 3.3% of eyes, howbeit more in group B eyes. FAS in both groups was also comparable, group B eyes now having 93.2% of eyes achieving FAS compared to 94.9% in group A. The differences were not statistically significant. These values were slightly better than our previous anatomic outcomes of 80.5% for PAS and 90.2% for FAS reported in our earlier study.
Controversy still remains whether there is an advantage of combining scleral buckles with vitrectomy for giant tears, some surgeons believe the scleral indentation from a buckle can distort the shape of the globe and might potentially increase the risk of GRT slippage; on the contrary, an encircling buckle may provide vitreous base support, particularly in the case of anterior PVR, and may reduce the risk of redetachment by preemptively neutralizing subsequent traction. In our study there was no significant difference between both groups in the use of combined procedures, scleral buckles were combined with vitrectomy in 14.8% of eyes in group A and 17.0% of eyes in group B. Surgeons were of the opinion that in peculiar cases the buckles could provide vitreous base support and reduce the risk of redetachment, indentation from the buckles also allowed better visualization and shaving of the periphery especially in phakic eyes.
Based on our previous study, we found a higher percentage (29.1%) of eyes had advanced PVR grade C-1 and worse, compared to a similar study carried out in East Africa (17.5%). Unfortunately, the data on PVR could not be included in this study, as there were inconsistencies in the medical records, surgeons had introduced different classifications for PVR in their records. Not withstanding complex pathologies, good anatomic outcomes were achieved with no significant differences between eyes with RRD from giant tears and RRD from other types of tears or holes.
Visual recovery is a major concern for both surgeon and patient; anatomic success alone is not sufficient to justify intervention. Although a higher percentage of eyes with other types of tears achieved good visual outcome when compared to eyes with giant retina tears (65.6% vs. 59.3%), this difference was not statistically significant. (P = 0.318)
Our study shows that outcomes of surgery for RD in our series of patients are comparable for detachments from giant retina tears and from other retina holes. The advent of better surgical techniques has contributed to improved surgical outcomes for retinal detachments from giant retina tears.,, The use of smaller gauge (23G, 25G) vitrectomy systems with trocars and cannulas, wider angle viewing, better illumination, and particularly the use of perflourocarbon liquids have all contributed to making surgery a more rewarding experience. Subsequently, many reports now show good surgical outcomes for RDs secondary to giant tears., However, few studies have evaluated the outcomes in sub-Saharan Africa setting, is this region of the world lagging behind &? When compared to other types of retina tears are giant tears still associated with poorer outcomes&? Our study shows the contrary, visual and anatomic outcomes are comparable with reports from other regions; detachments from giant retina tears also achieve good results comparable to those from other tears and holes. [Figure 1] shows an example of a middle aged professional who presented with visual acuities of counting fingers and RRD, he had vitrectomy with silicon oil and subsequently silicon oil removal after 4 months. Vision has improved to 6/18 best corrected with retina remaining attached even 2 years after his last surgery.
|Figure 1: (a) Rhegmatogenous retinal detachment with tears and holes is a middle-aged man. (b) Posterior pole of shallow RRD with macula off. (c) Retina drawing showing detachment and distribution of subretina fluid. (d) Ultrasound B scan showing total RRD. (e) Reattached retina with scarring over area of previous offending tear. (f) Posterior pole of reattached retina after removal of silicon oil|
Click here to view
| Conclusion|| |
Good anatomic and visual outcomes can be achieved after surgery for RRD secondary to giant tears in a sub-Saharan Africa setting in this era of small gauge vitrectomy and perflourocarbon use, these outcomes are comparable to those from surgery for RRD secondary to other types of tears and holes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]