Scleral buckling for stage 4 retinopathy of prematurity

BACKGROUND AND OBJECTIVE: Both vitrectomy and scleral buckling have been used to treat patients with stage 4 retinopathy of prematurity (ROP). The standard procedure of scleral buckling for treatment of stage 4 ROP is encircling scleral buckling. The effectiveness of segmental scleral buckling is still unclear. The purpose of this study was to analyze the surgical results of patients with stage 4 retinopathy of prematurity treated with either encircling or segmental scleral buckling. PATIENTS AND METHODS: We retrospectively analyzed the anatomic outcomes of 23 eyes (18 infants) with stage 4 A or B ROP treated with scleral buckling. Segmental buckling was used to treat 15 eyes with detachment limited to the temporal side of the retina, while 9 eyes with detachment involving both the nasal and temporal sides were treated with encircling scleral buckling. RESULTS: Macular reattachment during a mean follow-up period of 34 months (range: 2 weeks to 9 years) was accomplished in 11 (79%) of the 14 eyes treated with segmental scleral buckling and 4 (44%) of the 9 eyes that received encircling scleral buckling. There were no intraoperative complications recorded. None of the eyes that achieved macular reattachment developed recurrent macular detachment during the follow-up period. CONCLUSIONS: Scleral buckling appears to be effective for treatment of stage 4 ROP. In patients with temporal side retinal detachment only, segmental scleral buckling provides adequate treatment for stage 4 ROP.     

Laser therapy for retinopathy of prematurity

Retinopathy of prematurity (ROP) is a potentially blinding condition that afflicts preterm infants in the neonatal period. Although advances in scleral buckling and vitrectomy techniques offer hope for those infants suffering from stage 4 or 5 ROP, prevention of progression to these stages offers the most promise for favorable structural and visual outcomes. Proper screening for threshold ROP and treatment with peripheral retinal ablation are the keys to successfully managing ROP. Technological advances in screening tools and portable diode lasers enable ophthalmologists to provide prompt, effective, and safe treatment for patients with threshold ROP.     

Lens-sparing vitrectomy for stage 4 and stage 5 retinopathy of prematurity

PURPOSE: To describe the results of lens-sparing vitrectomy for the correction of retinal detachment associated with retinopathy of prematurity (ROP) and its associated complications. METHODS: Seventeen patients who underwent a lens-sparing vitrectomy for stage 4 and stage 5 ROP with plus disease at Seoul National University Children' s Hospital between 1999 and 2003 were enrolled in this study. The patients who had bilateral retinal detachment of ROP underwent a lens-sparing vitrectomy in one eye and a scleral buckling surgery or lensectomy-vitrectomy in the other eye. The patients who had a retinal detachment in one eye and a regressed ROP in the other eye underwent unilateral lens-sparing vitrectomies. A review of their preoperative clinical findings (including the status of retinal detachment and plus disease), post-operative results, and any complications encountered was performed. RESULTS: In 17 patients, the postoperative success rate of lens-sparing vitrectomy was 58.8%. However, lens-sparing vitrectomy as a treatment for stage 5 ROP (25.0%) produced more negative post-operative results than it did when used to treat either those for stage 4a (75,0%) or 4b (66.7%) ROP. Among the 10 eyes in which the retina was attached, form vision was shown in six eyes, light could be followed by three eyes, and no light perception was present in one eye. Intra- and post-operative complications included retinal break formation, cataracts, vitreous hemorrhages, and glaucoma in patients with stages 4b and stage 5 ROP. CONCLUSIONS: Lens-sparing vitrectomy resulted in encouraging surgical outcomes in the correction of retinal detachment of ROP, especially in stage 4 patients. Therefore, a lens-sparing vitrectomy for stage 4 ROP patient may be beneficial, although it is still associated with some intra- and post-operative complications.     

Outcomes of primary scleral buckling for stage 4 retinopathy of prematurity

BACKGROUND: Scleral buckling is an option for stage 4 retinopathy of prematurity (ROP). This study evaluated the anatomic results of a primary scleral buckling procedure for the treatment of this condition. METHODS: Retrospective analysis of cases in which premature infants were treated solely with a primary scleral buckling procedure for stage 4 ROP by 1 retinal specialist between January 1990 and April 2001. The 20 eyes, of 14 infants, had previously been treated with cryotherapy or laser photocoagulation ablation for threshold ROP, but stage 4 ROP had developed. Maintenance of an attached macula was the desired anatomic result of surgical treatment. RESULTS: Of the 20 eyes, 14 (70%) had an attached macula postoperatively. During a follow-up period of 3.5 to 28 months the retina redetached in 2 eyes, which became phthisical. The other 6 eyes also became phthisical, despite additional surgical treatment. INTERPRETATION: Primary scleral buckling has a high anatomic success rate in infants with stage 4 ROP, a rate thought to be higher than would occur with natural progression of the disease. Because an attached macula is associated with improved visual potential, timely primary scleral buckling is reasonable for these infants, offering a 60% chance of useful vision.     

Scleral perforation after scleral buckling surgery for retinopathy of prematurity

Scleral perforation occurred as a result of using a silicone band during scleral buckling surgery for subtotal retinal detachment in retinopathy of prematurity (ROP). The patient was initially treated by cryotherapy and scleral buckling surgery for ROP, and was later referred due to a dark bluish mass in the superotemporal quadrant of the eyeball. After removing the overlying whitish membrane, uveal tissue prolapsed through the melted scleral wound (5 mm x 5 mm). A silicone encircling band had passed through the wound and was exposed subconjunctivally around the temporal and the inferior limbus. The band was removed and a scleral allograft was performed. After three years, follow up revealed the eyeball was slightly microphthalmic. Though scleral bucking surgery is helpful for the treatment of advanced ROP, a scleral perforation may develop as a disastrous complication.     

Scleral buckling surgery for stage 4B retinopathy of prematurity.

Results of scleral buckling in 15 consecutive eyes of 13 infants with stage 4B retinopathy of prematurity (ROP) were reviewed. Ten of 15 retinas achieved macular reattachment with a single scleral buckling procedure. Four of 15 retinas unable to be attached by scleral buckling were reattached after the addition of a single vitreous operation. One of 15 retinas was unable to be reattached despite both a scleral buckling and a single vitreous procedure. Despite macular attachment in all except one eye, visual results were disappointing. Fix and follow visual acuity was present in 3 eyes, light perception in 11 eyes, and no light perception in 1 eye. Average follow-up was 10 months. Possible causes for poor visual outcomes despite retinal reattachment include retinal abnormalities as a result of detachment and amblyopia.     

Late-onset retinal detachment associated with regressed retinopathy of prematurity

PURPOSE: To study the characteristics of late-onset retinal detachments in patients with regressed retinopathy of prematurity (ROP) and the condition of their fellow eyes. METHODS: We carried out a retrospective review of 29 patients (38 eyes) who had been treated at two institutions, one in the US and the other in Japan, between 1986 and 1997. The age at the time of treatment ranged from 6 to 51 years (mean=23.1). Five of the 38 eyes with tractional detachment were treated with either open-sky vitrectomy, closed vitrectomy, or scleral buckling; 27 of the 38 eyes with rhegmatogenous retinal detachment underwent scleral buckling or closed vitrectomy or both. The remaining 6 of the 38 eyes had subclinical rhegmatogenous detachment and were treated with photocoagulation or cryopexy, or followed without treatment. The most characteristic retinal breaks were multiple holes with a prevalence of equator and posterior types. RESULTS: Overall, anatomical reattachment was accomplished in 27/32 eyes (84%) that underwent surgery. Two thirds of the patients who underwent vitrectomy either initially or at a later time had poor postoperative visual acuity. More than half of the fellow eyes had retinal detachment and others had various characteristic fundus changes of regressed ROP. CONCLUSIONS: Long-term, probably life-long follow-up of high-risk patients is necessary so that diagnosis and treatment can be instituted at an early stage of retinal detachment.     

Features associated with surgical outcome in patients with stages 4 and 5 retinopathy of prematurity

PURPOSE: To present ocular features associated with surgical outcomes in infants with stages 4 and 5 retinopathy of prematurity (ROP). METHODS: Twenty-two infants (35 eyes) were referred for vitreoretinal surgery for stages 4 and 5 ROP. The following ocular features recorded before the development of retinal detachment requiring surgical intervention were analyzed: clock hour extent of ridge elevation, vitreous state, plus disease, prominent iris vessels, neovascularization, and the presence of exudates. Surgical procedures included scleral buckle, lensectomy-vitrectomy, and lens-sparing vitrectomy. Univariate and multivariate analyses were used to determine features associated with failure to achieve retinal reattachment as the main outcome variable. RESULTS: Of the 35 eyes that underwent at least one surgical procedure, nine had successful retinal reattachment after the first surgery, and 18 achieved it at the end of follow-up. After accounting for the correlation between the eyes, features significantly associated with surgical failure after the first surgery were vitreous haze, hemorrhage, or organization; plus disease; and neovascularization. The presence of exudates was significantly associated with a successful outcome. When eyes were analyzed by stage at the first procedure, vitreous organization and plus disease were associated with failed retinal reattachment in stage 4 eyes, whereas at least 6 clock hours of ridge elevation and plus disease were significant in stage 5 eyes. The need to perform a lensectomy-vitrectomy was associated with a poor surgical outcome. Neither stage nor number of procedures performed was associated with the development of phthisis. CONCLUSIONS: Vitreous haze, neovascularization, and plus disease are associated with a poor surgical outcome in eyes that progress after treatment for threshold ROP requiring surgical intervention for retinal detachment. When eyes were divided by stage of ROP at first surgery, plus disease remained a significant variable associated with failed retinal reattachment. Close observation of eyes after laser treatment for threshold ROP is necessary. If neovascularization and plus disease persist and progression of ROP is noted, additional laser should be considered before surgery for retinal detachment. Additional studies with a larger patient sample will be necessary to further define ocular features associated with surgical outcome for ROP.     

巩膜扣带术治疗视网膜脱离118例临床分析

目的 对原发怍（孔源性）视网膜脱离行巩膜扣带术治疗并对其效果进行评价。方法 对118例118眼原发性视网膜脱离病人行巩膜扣带术治疗。术中直接检眼镜定位，放视网膜下液，巩膜外液氮冷凝，巩膜扣带或环扎术。结果 术后随访1周至半年，视网膜裂孔封闭、完全复位107眼（90．68％），视力提高90眼（76.27％）。结论 巩膜扣带术是治疗原发性视网膜脱离常用有效的方法。     

Results of treatment of retinal detachment in active stage-5 retinopathy of prematurity

PURPOSE: To evaluate the surgical and functional results of encircling scleral buckling in treatment of active stage 5 retinopathy of prematurity. MATERIAL AND METHODS: 68 premature infants (121 eyes) with active stage 5 ROP operated with the use of the modified encircling buckling technique. The surgical and functional results were compared with the results observed in 91 unoperated children with active stage 5 ROP. RESULTS: In the operated group total retinal reattachment was observed in 52% and partial reattachment in 24.5% of premature infants. The surgery failed to reattach the retina in 23.5%. Visual acuity was: no light perception in 56.1%, light perception to 0.02 in 24.5% and 0.02 to 0.2 in 19.4% of children. In unoperated group spontaneous reattachment was observed in 6% of infants and visual acuity was: no light perception in 76%, light perception in 20% and finger counting in 4% of them. CONCLUSION: The obtained results indicate, that modified encircling buckling can be an effective treatment in reattaching the retina in stage 5 ROP although useful vision can be obtained in only 20% of operated children.     

Management of pseudophakic retinal detachment with undetectable retinal breaks

BACKGROUND AND OBJECTIVE: Difficulties encountered during the repair of pseudophakic retinal detachment are related to difficulties in peripheral retinal visualization and identification of retinal breaks. The implication of nonvisualized breaks in patients with pseudophakic retinal detachment is associated with lower rates of surgical success. This report decribes the results of a prospective trial to evaluate the efficacy of both scleral buckling surgery in the treatment of pseudophakic retinal detachment with undetected retinal breaks and pars plana vitrectomy techniques in the management of the cases that redetected after primary buckling surgery. PATIENTS AND METHODS: This study represents 25 cases of pseudophakic retinal detachment with undiagnosed retinal breaks. In each case, we performed a scleral buckling that extended over the circumference of the retinal detachment. Pars plana vitrectomy with internal subretinal fluid drainage and long-term tamponade were performed on 7 patients with uncomplicated recurrent retinal detachments after primary buckling surgery. The mean duration of follow up was 32 months. RESULTS: There were 25 eyes (24.5%) of pseudophakic retinal detachment with undiagnosed retinal breaks represented in our pseudophakic retinal detachment cases. Anatomic success was achieved after the initial scleral buckling surgery in 18 eyes (72%). The overall success rate was 92%. The visual acuity was 20/40 or better in 8 patients (32%), 20/80 to 20/40 in 6 patients (24%), 5/200 to 20/80 in 7 patients (28%), and light perception to hand movement in 4 patients (16%). Complications included vitreous hemorrhage, macular pucker, cystoid macular edema, and hypotony with proliferative vitreoretinopathy. CONCLUSION: Scleral buckling surgery in conjunction with cryotherapy is effective in the initial treatment of pseudophakic retinal detachment with undetectable retinal breaks. Pars plana vitrectomy with internal fluid-gas exchange and long-term tamponade can be used to treat these patients with recurrent retinal detachment after primary buckling surgery to get a higher overall success rate.     

巩膜环扎术预防穿孔性眼外伤后视网膜脱离

在４５例累及后段的穿孔性眼外伤病例行玻璃体切割术中，随机对其中２５例同时行预防性巩膜环扎术，观察环扎术对后期视网膜脱离发生率的影响。环扎术采用３ｍｍ宽的硅胶带置于角巩缘后９ｍｍ至１２ｍｍ之间，形成一个中等高度的巩膜嵴。经６个月以上的随访，行环扎术的２５例中发生视网膜脱离５例（２０％）；未行环扎术的２０例中有７例发生视网膜脱离（３５％）（Ｐ＜０．０５）。本结果显示：预防性巩膜环扎对穿孔性眼外伤后期视网膜脱离发生率的降低是有益的。     

Late onset vitreoretinal complications of regressed retinopathy of prematurity

AIM: To report the clinical findings, management, and outcomes in eyes undergoing surgery for regressed retinopathy of prematurity (ROP) with vitreoretinal complications. METHOD: Retrospective review of 40 eyes of 32 patients with regressed ROP who presented between 1989 and 2001 at two UK referral centres. RESULTS: Of 29 eyes presenting with rhegmatogenous retinal detachment (RRD), 15 initially underwent a scleral buckling procedure and 14 initially underwent vitrectomy with or without additional buckling. Primary surgery was anatomically successful in 11/15 eyes that underwent a non-vitrectomy retinal detachment repair and 8/14 that required vitrectomy. The final reattachment rate after reoperation was 28/29 eyes. Median visual acuity improved from 6/60 to 6/36 following retinal detachment repair. A further 11 eyes of eight patients from this series underwent prophylactic surgery, laser, or cryotherapy for predisposing vitreoretinal pathology and/or retinal breaks, all of which were stabilised. CONCLUSIONS: In eyes with RRD and signs of regressed ROP successful reattachment of the retina can be achieved using either vitrectomy or external surgery with an associated overall improvement in visual acuity. A range of external and closed microsurgical approaches is required to effectively deal with the diverse manifestations of regressed ROP.     

光凝与冷凝在孔源性视网膜脱离手术中的比较

目的　观察两种视网膜脱离手术的疗效并进行比较。方法　回顾分析 2 0 0 1年～ 2 0 0 2年因视网膜脱离行手术治疗的 30例病人。其中一组手术方式为巩膜扣带术联合术后激光治疗 ,另外一组为冷凝加巩膜扣带术 ,随访时间为 3个月至 1年。结果　两组视网膜复位率均为 88.6 7% ,差异无显著性 (P >0 .0 5 )。结论　巩膜扣带术联合术后激光治疗是治疗孔源性视网膜脱离的一种可行的方法 ,其疗效等同于传统的冷凝加巩膜扣带术。     

单纯气液交换联合环扎治疗玻璃体切割术后视网膜脱离的疗效

目的 分析单纯气液交换联合环扎手术治疗玻璃体切割术后视网膜脱离的效果以及影响因素.方法 收集2005年1月至2007年6月应用单纯气液交换联合环扎手术治疗玻切术后视网膜脱离的临床资料,应用Pierce考马斯亮蓝比色法测定术中取出的玻璃体腔液体蛋白质总浓度.分析影响手术效果的可能因素.结果 单纯气液交换联合环扎手术治疗玻切术后视网膜脱离共19例(19只眼),手术成功率为78.9%.失败4只眼均为下方裂孔,视网膜脱离时间平均11.3d,3只眼为视网膜全脱离.蛋白质浓度手术失败眼与成功眼差异有显著性(P<0.01.结论 单纯气液交换联合环扎治疗玻切术后视网膜脱离可以获得较好的疗效.对于下方裂孔并且视网膜脱离时间长,范围大的患者应采用再次玻璃体手术.     

Minimally invasive method for repair of rhegmatogenous retinal detachment following treatment for retinoblastoma.

A minimally invasive method for repair of rhegmatogenous retinal detachment following treatment of retinoblastoma is described. Two children with retinoblastoma developed rhegmatogenous retinal detachments following treatment with a combination of chemotherapy and cryotherapy. Each eye underwent a non-drainage scleral buckling procedure without retinopexy of the retinal break. Postoperatively, the retinas reattached and retinopexy with indirect laser photocoagulation was performed during subsequent examinations under anesthesia. The retinas have remained attached with 2 to 5 years of follow-up. The tumor recurred in case 2, was treated with additional chemotherapy, and has undergone type 1 regression. Non-drainage scleral buckling without retinopexy is a useful technique for repairing rhegmatogenous retinal detachment in eyes with retinoblastoma. The retinal break can be treated postoperatively with indirect laser photocoagulation to minimize the chance of viable tumor cell dissemination.     

Retinopathy of prematurity: approaches to surgical therapy

Retinopathy of prematurity (ROP) is a vasoproliferative disease with infiltration of the vitreous gel. Contraction of the infiltrate results in traction detachment with typical peripheral trough formation. Cryotherapy inhibits proliferation in the active stages of the disease (Stage 3, 'plus'). With development of traction detachment involving the macula (Stage 4B) encircling buckling procedures should first be tried. Closed vitrectomy is considered when high retinal detachment and opacification by vitreous strands occur. The surgical technique is described. Anatomical (64%) and functional (43%) successes are reasonably high for Stage 4 cases, but disappointing (anatomical 40%, functional 16%) for Stage 5 ROP. Open funnels of detached retina fare better than closed ones. It is probably best to perform surgery not before the cicatricial stage, i.e. six months after birth.     

光导直视下巩膜扣带术治疗硅油眼视网膜脱离的临床分析

目的 总结硅油填充眼视网膜脱离复发时应用光导直视下巩膜扣带术治疗的效果.方法 对就诊于吉林大学第二医院并接受光导直视下巩膜扣带术治疗硅油眼视网膜脱离复发的12例(12只眼)患者进行回顾性分析.结果 应用光导直视下巩膜扣带术治疗后网膜复位11只眼(91.7%),其中8只眼行硅油取出术后网膜保持复位.术眼均保持了一定视力,其中4只眼(33.3%)视力在0.1以上.结论 对于硅油填充术后视网膜再脱离范围局限、前部PVR轻微、裂孔较明确、多位于赤道前、下方裂孔、伴有孔缘局部网膜僵硬的上方裂孔的患者,采用光导直视下行裂孔冷冻、巩膜外垫压或联合环扎术进行治疗,取得了较好的治疗效果.     

巩膜外垫压术治疗家族性渗出性玻璃体视网膜病变合并孔源性视网膜脱离

目的 探讨巩膜外垫压术治疗家族性渗出性玻璃体视网膜病变合并孔源性视网膜脱离的效果.方法 回顾性分析2011年1月至2012年10月间在我院住院行巩膜外垫压术（或联合环扎术）治疗的6例（6只眼）家族性渗出性玻璃体视网膜病变合并孔源性视网膜脱离患者的临床资料.本组所有患者视网膜裂孔检查明确,且位于赤道或赤道前,增生性玻璃体视网膜病变C2级以下;具有阳性家族史;荧光素眼底血管造影特征明显.其中1个裂孔者4只眼,2个裂孔者2只眼.1例硅胶海绵纵行垫压,5例硅胶轮胎环行垫压并联合环扎.所有患者术后均补充视网膜激光光凝.结果 6例患者术后视网膜均复位良好,视力改善,经激光治疗无灌注区,随访稳定.结论 对于家族性渗出性玻璃体视网膜病变合并孔源性视网膜脱离患者,选择部分病例行巩膜外垫压手术治疗,术后及时补充视网膜激光光凝,可取得很好效果.     

An evidence-based analysis of surgical interventions for uncomplicated rhegmatogenous retinal detachment

PURPOSE: To evaluate the various surgical interventions available for uncomplicated rhegmatogenous retinal detachment. METHODS: Reports of controlled clinical trials of surgical interventions (pneumatic retinopexy, scleral buckling and vitrectomy) for uncomplicated rhegmatogenous retinal detachment indexed in MEDLINE from 1968 to January 2006 were included. The primary outcomes evaluated included single-operation reattachment rates, multiple reoperation reattachment rates and improvements in visual acuity (VA). RESULTS: We found five controlled trials (two randomized) comparing the efficacy of pneumatic retinopexy versus scleral buckling. The single-operation reattachment rates were higher for scleral buckling, but the final reattachment rates were similar. We found nine controlled trials (four randomized) evaluating vitrectomy. There were no statistically significant differences between retinal reattachment rates or final visual acuities, except in one randomized and one non-randomized controlled trial in which the VAs were significantly better in the vitrectomy than the scleral buckling group. CONCLUSIONS: Pneumatic retinopexy is a possible alternative to scleral buckling in the treatment of uncomplicated rhegmatogenous retinal detachment. The rates of missed or new retinal breaks after pneumatic retinopexy, however, are higher than following scleral buckling. The clinical outcomes of vitrectomy for rhegmatogenous retinal detachment compare favourably.