Episcleral Compression or Pars Plana Vitrectomy for Retinal Detachment: Buckle or Bubble?

Having the opportunity to work in two countries (Serbia and Switzerland) with very different health care systems, I have tried to “pick up” the best tips for dealing with rhegmatogenous retinal detachment (RRD) from both worlds.

When I examine patients in these far different systems, I need to adapt fast to the “rules” in both countries. While in Lausanne, Switzerland, the method of choice for RRD treatment in most cases is pars plana vitrectomy. In Belgrade, Serbia, it is scleral buckle. This way, I have the opportunity to see the results, as well as “pros and cons” of both surgeries performed in a large spectrum of indications.

Unfortunately, buckling is a technique that is slowly dying out in western countries, as it requires great skill, training and lots of time invest for both, fellow and his mentor; luckily, this art is being kept alive in Belgrade, with long tradition of buckling. I feel that this opportunity made me richer in knowledge and has broadened my horizons in making the best decision for the patient.

The incidence of RRD is estimated to be one in 10,000 per year, increasing to about 3.5% to 5.8% in the first year and 9% to 10% within four years in the second eye. Recent research has, however, shown a very intriguing trend towards a 50% increase of the incidence of RRD over the past 10 years in Scotland and the Netherlands, potentially linked to an increase in cataract operations and myopia.

RRDs represent an ophthalmic emergency: if not treated, it can lead to severe loss of vision. The emergency for surgery depends on whether the macula is attached (macula-ON RD) or detached (macula-OFF RD). The degree of postoperative functional recovery has been associated with several factors, the most important of which are the duration of RD, degree of myopia (axial length of the globe), age, and persistence of sub-retinal fluid (SRF).

Since photoreceptor cell death starts within the first twelve hours and peaks at two to three days following RD, it is important to perform surgery as quickly as possible once the macula is detached. Recent research has shown that the best visual recovery can be achieved if macula-OFF RDs are operated on within three days of the macular detaching.

The timing also depends on:

• Location of RD: superior or inferior (inferior RD gives larger margin timewise as SRF will not advance quickly against gravity and may have been present for a long time before the patient realized a problem in his superior visual field)
• How peripheral the RD is: if more peripheral, the larger margin
• The velocity of visual loss (curtain appearance), or how bullous it is: more bullous and more sudden vision loss, the more urgent the surgery
• It is very important to always position the patient on the side of the retinal break before surgery. That way the advancement of RD is limited. and it will help to absorb excess SRF before surgery.

Table 1. Referral Procedure for RD

Adapted from (Williamson, Shunmugam et al. 2013)

The most common symptoms of a patient presenting with RD at emergencies (see Figure 1 in slideshow below):

• Sudden vision loss in a part of visual field (RD)
• Curtain/web gradually growing in front of the eye (RD)
• {resence of flashes several days preceding vision loss (vitreo-retinal traction)
• “Mouches volantes” or “black points and lines” moving with the gaze (vitreous opacities or vitreous hemorrhage)

For the diagnosis of RD, there is no need for expensive and special instruments. The diagnosis is made on the basis of anamnesis and detailed ophthalmological exam (visual acuity, intraocular pressure, slit lamp examination) with dilated pupils. The crucial part of the exam is indirect ophthalmoscopy of the central and peripheral retina. In the case of optical media opacification (dense cataract, vitreous hemorrhage etc), the diagnosis is made by ultrasound. Recently, in some hospitals, optical coherence tomography (OCT) is used more and more, in order to assess precisely the extent of fluid under the macula (Figure 2 a, b, c).

The key to successfully resolving primary rhegmatogenous retinal detachment is to identify and close all retinal breaks.

There are two main surgical methods (or, in some indications, their combination):

• Scleral buckling (SB) (Figure 3)
• Pars plana vitrectomy (PPV) (Figure 4)

Both surgical techniques are good and have their application. Although each technique has potential benefits and disadvantages, there is no consensus on the best surgical approach for the management of uncomplicated RRD.

The best for the patient is to perform the method that the surgeon feels more comfortable with (the hidden rule). The basis of both methods is the closure of all retinal breaks by external scleral buckle or by internal gas or silicone oil tamponade and by cryopexy or endolaser photocoagulation.

General characteristics and differences between two surgical methods are listed in Table 2.

Table 2. Characteristics of SB and PPV

SB is a method that cannot be applied in all cases of RD and it requires careful selection of patients. SB is the method of choice for:

• Young patients with RD, where the vitreous is very viscous and adherent to the retina
• RD with one clear retinal break or 2 breaks in the same quadrant
• RD not involving significant part of the retina (< 3 quadrants)
• Retinal dialysis
• It is also a superior technique for patients with their own, natural lens (phakic).

PPV has greatly contributed to increasing the success rate for those types of primary RD that could not be resolved, or were difficult to resolve with SB technique, such as:

• more complicated and older RDs
• RDs with multiple breaks,
• large and giant retinal breaks
• complicated RDs with proliferative vitreoretinopathy (PVR), epiretinal membranes (ERM),
• in aphakic and pseudophakic eyes

The relationship between these two surgical techniques is shifting in favor of PPV, but SB remains an important and relevant surgical technique. For well-selected cases, the results of SB may be superior to PPV.

Finally, apart from the surgical success, managing patient’s expectation is one of the most crucial aspects of retinal surgery. The points in this context are the fact that up to 10% of operated cases will show a recurrence of retinal detachment and this needs to be discussed with the patient ahead of the first surgery.

When vitrectomy and gas is used in macula-on RDs visual acuity usually drops in the first few weeks as the gas in the posterior cavity will distort the optical system of the eye and patients need to be prepared for this temporary worsening of visual acuity.

About the author: Jelena Potic, MD, PhD, is a fellow in vitreoretinal surgery at the Jules-Gonin Eye Hospital, University of Lausanne, Switzerland, and is currently working in the vitreoretinal surgery unit at the Clinic for Eye Diseases, Clinical Center of Serbia, University of Belgrade, Serbia. She is also an assistant professor at the School of Medicine, University of Belgrade, Serbia, and has received the “Junior Clinical Scientist” award from Fondation Leenaards and the School of Biology and Medicine, University of Lausanne, Switzerland. As such, she is building stronger bridges of collaboration between these two countries. Dr. Potic is a committee member and chair-elect of the European Society of Ophthalmology – Young Ophthalmologists (SOE-YO) and a participant in the Academy’s Leadership Development Program XXII, Class of 2020.