Introduction to Glaucoma and the Retina Nerve Fiber Layer (RNFL) – Dr. Oli
Introduction to Glaucoma We have spoken about the importance of the way the front of the optic nerve looks like …more >
Now that I have been in Central Oregon for five years I thought it would be an appropriate time to review my surgical results for retinal detachments.
Reviewing a surgeon’s results helps educate the surgeon, the referring doctors, and most importantly the patients. Naturally, surgical results vary. These variations depend on the surgeon as well as the patients.
Retinal detachment treatment has evolved over the last 15 years. There has been a transition away from scleral buckling as well as the advent of small-gauge vitrectomy. International conferences regularly discuss the pros and cons of all retinal detachment techniques and tamponade agents as well as surgical approaches. There still is little consensus. And, the bottom line is: what is each surgeon’s success with whichever modality they chose?
Personally I prefer primary small-gauge vitrectomy with either SF6 or C3F8. I use silicone oil and scleral buckle in select cases if I feel the patient is likely to have a higher rate of success with that approach or if there are extenuating circumstances (for example, a patient with a macula-sparing retinal detachment, who lives in Florida…).
I had a few questions that I personally wanted to answer… First, I take ‘fresh’ macula-off retinal detachments to surgery as quickly as possible (i.e., within 24-48 hours of diagnosis). I wanted to know; do visual outcomes vary among detachments that have been present for 2 days compared to 4 days? Second, I was interested to know what the visual prognosis was for retinal detachments that had been present for longer than a month; how should I consent the patients? What hope is there?
In 5 years, I have done 134 retinal detachment repairs. Of those detachments, 52 were macula-sparing. Each year, I have done more retinal detachments (Chart 1)…
Published statistics vary regarding primary success in retinal detachment repairs. The averages are 80-90%. In the five year review, ESI has a 91% primary success rate at primary repair. In addition, the success rates vary if multiple surgeries are required to achieve anatomic success. Some reports are 90-95% anatomic success with multiple surgeries. ESI has a 96% anatomic success after multiple surgeries. Some patients who did not reach anatomic success voluntarily chose not to pursue more surgery; two patients were diagnosed with cancer, another decided that the vision had always been so poor in the eye that he didn’t want more surgery and another patient was admitted to hospice.
Of the 13 patients who failed primary repair, 5 had proliferative vitreoretinopathy prior to initial repair. Two patients had a history of failed pneumatic retinopexy performed by other practitioners and two had a concomitant diagnosis of retinoschisis.
One of the most common reasons for a failed retinal detachment repair is the development of proliferative vitreoretinopathy. In published reports, the incidence of PVR ranges from 8-10%. ESI has a 6% occurrence of PVR.
Finally, the visual acuity results of patients with a retinal detachment….
If the retina is repaired while the macula is still ‘on’, the likelihood of achieving vision better than 20/40 is 93%. If the macula was detached but was repaired within 2 days, 100% of those patients had 20/40 vision or better. If the macula was detached less than a week, 73% of those patients were better than 20/40. If the macula was detached longer than 1 month, 27% of those patients were 20/40, or better.
So, my take home message was this; time is gold. Repairing the retinal detachment sooner is helpful. Ideally, the retina is repaired while the macula is still on. However, even days matter once the macula is detached. And even if the retina has been detached longer than a month it is still worth trying to improve the vision, since a good portion of these patients end up with functional vision.
Lastly, complete examination of the contralateral eye including a thorough scleral depressed exam is critical. A total of 48% of patients had pathology in the contralateral eye. Retinal detachments occurred in 15% of these patients and 32% had either a retinal tear or lattice in the unaffected eye.
In conclusion, patient education is critical. The patient needs to be educated about the likelihood of anatomic and visual outcomes with surgical repair of their retinal detachment as well as the risk to their contralateral eye.