Persistent foveal retinal detachment after successful rhegmatogenous retinal detachment surgery

PURPOSE: To describe the tomographic features of the neurosensory retina after successful rhegmatogenous retinal detachment surgery. DESIGN: Cohort study. METHODS: We prospectively examined cross-sectional retinal images using optical coherence tomography (OCT) in 15 eyes of 15 consecutive patients (mean age, 46 years) who underwent scleral buckling surgery for treatment of rhegmatogenous retinal detachment. The retinas appeared reattached upon binocular stereoscopic indirect ophthalmoscopy. All eyes were examined at 1, 3, 6, and 12 months postoperatively. The time from onset of subjective symptoms of retinal detachment to retinal surgery ranged from 4 to 66 days (mean, 14 days). The postoperative OCT findings and best-corrected visual acuity were statistically analyzed using the Mann-Whitney U test. RESULTS: The detached retinas appeared attached on ophthalmoscopy in all eyes 1 month postoperatively. OCT showed residual retinal detachment in four eyes (27%) at the fovea and in three eyes (20%) at the fovea and adjacent area. The remaining eight retinas (53%) were attached when examined tomographically. In six of the seven eyes with residual foveal detachment by OCT, the retinas reattached spontaneously up to 12 months postoperatively. The postoperative best-corrected visual acuity improved gradually during 12 postoperative months in all 15 eyes. A substantial increase in visual acuity occurred when the fovea reattached in the six eyes with residual detachment. CONCLUSIONS: Foveal retinal detachment may persist after successful retinal detachment surgery in eyes in which the fovea appeared to be attached on ophthalmoscopy. The residual foveal detachment may explain, in part, the delayed visual acuity improvement after successful scleral buckling.     

Persistent foveal retinal detachment after successful rhegmatogenous retinal detachment surgery by scleral buckling

We report the case of a phakic patient with late visual recovery after successful surgery of macula-off retinal detachment, using the scleral buckling procedure. Visual acuity remained low because of the persistence of subfoveal fluid despite the reattachment of peripheral retina. The amount of subfoveal fluid decreased slowly and final visual acuity finally recovered. We used optical coherence tomography (OCT) to quantify the remaining subfoveal fluid. Persistence of submacular fluid can explain late visual recovery after surgical treatment of retinal detachment.     

孔源性视网膜脱离手术复位后黄斑下积液

目的 探讨孔源性视网膜脱离经不同复位术式后黄斑下积液发生情况.方法 病例对照研究.选择手术治疗后视网膜解剖复位的新发孔源性视网膜脱离患者66例(67只眼).按复位术式分为玻璃体切除术组和巩膜扣带术组;巩膜扣带术中因封孔方式不同和放液与否相应分为冷凝组与光凝组、放液组与不放液组.术后1个月均常规行相干光断层扫描(OCT),了解黄斑下积液的发生情况.结果 玻璃体切除术组和巩膜扣带术组中,黄斑下积液发生率分别为21.7%和47.7%,差异有统计学意义(x2=4.296,P＜0.05).在巩膜扣带术中,冷凝组与光凝组、放液组与不放液组中的黄斑下积液发生率差异均无统计学意义(x2=0.091,1.588;均P＞0.05);但黄斑未脱离眼与脱离眼的黄斑下积液发生率(21.1%,68.0%)差异有统计学意义(x2=9.537,P＜0.01).黄斑下积液眼与未积液眼术后1个月视力提高2行以上的百分比相近(80.8%,80.1%),两者的术前及术后LogMAR值差异无统计学意义(F=0.162,P=0.688).结论 玻璃体切除术后黄斑下积液发生率明显低于巩膜扣带术.在巩膜扣带术中,光凝与冷凝、放液与否等手术操作差异对黄斑下积液发生率无明显影响,但黄斑脱离眼中黄斑下积液发生率较高.(中华眼科杂志,2008,44:223-228)     

Late recurrences more than 1 year after primary successful surgery for rhegmatogenous retinal detachment

BACKGROUND: Recurrent retinal detachment following initial successful surgery usually occurs in the early postoperative course. Redetachment after 1 or more years of complete retinal reattachment is a rare event. The present study investigates the frequency and causes of late recurrences. PATIENTS/MATERIAL AND METHODS: A consecutive series of 2,232 eyes that presented with rhegmatogenous retinal detachment (RD) were treated between January 1994 and December 2006. Among them were 30 cases (30 eyes) presenting with late recurrent RD (1.34 %). We compared the clinical characteristics of initial and late recurrent RD. RESULTS: Over the 13-year period, 54.5 % of rhegmatogenous RD cases were treated with scleral buckling, 42.5 % using vitrectomy techniques and 2.55 % with pneumatic retinopexy. Late recurrent RD occurred 1.1 - 10.4 years (average 3.8, SD 2.56) after initially successful surgery. Previous surgery included scleral buckling in 24 eyes (80 %), vitrectomy in 5 eyes (16.7 %) and pneumatic retinopexy in another eye (3.3 %). At the time of initial treatment, primary reattachment rate was 93.3 % and final 100 %. At the time of late redetachment, the anatomic situation appeared more complex. Accordingly, most eyes were treated by vitrectomy (73.3 %), and only 23.3 % using buckling techniques. Furthermore, the numbers of reoperations to achieve reattachment increased from 6.6 % to 23.3 %. Major causes for late failures were vitreous base traction leading to new or reopened breaks and PVR. Three eyes showed these complications immediately after complicated anterior segment surgery. Comparing visual outcomes after initial (preop logMAR 0.57 +/- 0.7 and postop 0.38 +/- 0.43) and late (preop logMAR 0.87 +/- 0.71 and postop 0.66 +/- 0.5) RD, functional prognosis is worse when redetachment occurs. Nonetheless, in 50 % of eyes useful vision (>or= 20 / 50) was retained by repeat surgery. CONCLUSIONS: Recurrent retinal detachment that presents after more than 1 year of complete reattachment occurs in 1.34 % of cases according to the present study. We found a higher rate after scleral buckling compared to vitrectomy. The most important reasons for late failures are vitreous base traction and periretinal proliferations that clinically appear as new or reopened tears or as PVR. Recurrences show a more difficult retinal situation and require more extensive surgical interventions. Based on the anatomic and functional success rates, repeat surgical procedures are worth considering.     

孔源性视网膜脱离术后黄斑形态和视力的研究

目的 观察孔源性视网膜脱离修复术后黄斑区视网膜形态及术后视力恢复情况并研究影响术后视力的相关因素.方法 收集行玻璃体手术或巩膜扣带术成功复位病例,所有病例病程少于1个月,按术前视网膜脱离是否累及黄斑区进行分类,术前和术后均行眼科常规检查和光学相干断层扫描(OCT)检查,随访半年.结果 共收集孔源性视网膜脱离101只眼,其中脱离累及黄斑区为78只眼.行玻璃体手术为36只眼,巩膜扣带术为65只眼,术后半年内均未发生并发症.术后一个月时复查OCT,在玻璃体手术组和巩膜扣带术组分别有55.56％和72.31％的患眼存在黄斑区视网膜形态异常,其中神经上皮层下积液多见.两种手术方式对术后黄斑区视网膜形态有影响(x2=23.65,P＜0.01).在巩膜扣带术组,术前视网膜脱离是否累及黄斑对术后黄斑区视网膜形态有影响(x2=30.331,P＜0.01),对术后视力提高程度有影响(F =8.150,P＜0.01).结论 视网膜脱离修复术的手术方式对术后黄斑区视网膜形态有影响.行巩膜扣带术病例如术前视网膜脱离累及黄斑,术后出现黄斑区视网膜形态异常的可能性大,术后视力恢复差.     

Microcirculation in eyes after rhegmatogenous retinal detachment surgery

PURPOSE: To investigate the tissue blood flow in the neuroretinal rim of the optic disk and macula after rhegmatogenous retinal detachment (RRD) surgery. METHODS: Tissue blood flow in the neuroretinal rim of the optic disk and macula was measured with the Heidelberg retina flowmeter in 53 eyes of 53 patients who had undergone successful surgery for unilateral RRD. Patients were divided into three groups; those who had the RRD treated by conventional encircling scleral buckling (group E), by local buckling (group L), and by primary vitrectomy (group V). Blood flow measurements were made more than 6 months after surgery in a 10 degrees x 2.5 degrees area of the superior and inferior margins of the neuroretinal disk rim and of the superior and inferior macula area. The mean blood flow (MBF) and the ratio of the MBF in the affected eye to the healthy fellow eye (a/f ratio) were compared among the three groups. The influence of several clinical factors on the MBF was also investigated. RESULTS: The MBF rate and mean a/f ratios of the MBF of the three groups were not significantly different. Multiple regression analysis revealed that the averaged MBF both at superior and inferior disk rims was significantly correlated with only the gas tamponade procedure. CONCLUSIONS: The ocular microcirculation is normal 6 months after scleral buckling or vitrectomy for RRD. However, the use of gas tamponade might have a subclinical adverse effect on the circulation in the neuroretinal disk rim.     

孔源性视网膜脱离术后增生性玻璃体视网膜病变形成的危险因素

目的 分析孔源性视网膜脱离玻璃体手术后增生性玻璃体视网膜病变(PVR)形成的危险因素。方法 孔源性视网膜脱离110例(112眼)行玻璃体切割术，术后随访6—32个月(平均8．4个月)。结果 112眼中34眼(30.4％)形成术后PVR。多因素逐步回归分析显示，术前PVR为影响术后PVR形成的重要危险因素(P＝0．001)，而硅油填充、巨大视网膜裂孔、合并脉络膜脱离等因素与术后PVR的形成无显著相关。术前PVR者手术成功率明显降低。结论 影响术后PVR形成的重要危险因素为术前PVR。对于有术前PVR可能导致术后PVR形成的高危人群可行预防性治疗。     

白内障术后视网膜脱离的治疗

目的探讨白内障术后孔源性视网膜脱离的手术方法及效果。方法本组23例(23眼),8例行最小量巩膜外垫压术,15例行玻璃体切除术,术后随访3~24月。结果本组23例中,20例视网膜复位,另3例视网膜脱离复发,经再次手术视网膜复位。术后视力提高20例,不变3例。结论最小量巩膜外垫压术或玻璃体切除术可有效地治疗白内障术后孔源性视网膜脱离。     

巩膜外路手术联合术后眼底激光治疗孔源性视网膜脱离

目的讨论巩膜外路手术联合术后眼底激光治疗单纯孔缘性视网膜脱离的临床疗效。方法对591例592眼单纯性视网膜脱离病人行巩膜外路手术，包括：巩膜外加压、放液或不放液，部分病人联合环扎或玻璃体腔注C，R气体，术后氩激光或532激光治疗视网膜裂孔。结果视力提高414眼，不变166眼，下降12眼。视网膜复位情况：完全复位561眼（成功率95％），部分复位24眼，未复位7眼。接受一次手术558眼，接受二次手术（包括玻璃体手术）29眼，接受三次手术1眼，7例7眼病人自动放弃。视网膜复位不良手术失败的原因依次为：玻璃体出血、脉络膜脱离型网脱、马蹄形视网膜裂孔伴牵引、黄斑裂孔、锯齿缘离断，以上均与PVR关系密切。结论选择适当病例，巩膜外路手术联合术后激光治疗孔源性视网膜脱离是一种安全、可行、简便、易操作、效果良好的方法。     

Ciliochoroidal detachment following scleral buckling surgery for rhegmatogenous retinal detachment

PURPOSE AND METHODS: We observed the peripheral choroid; ciliary body, and depth of the anterior chamber by ultrasound biomicroscopy (UBM) in 31 eyes with rhegmatogenous retinal detachment before and after scleral buckling surgery. Scleral encircling was performed in 11 eyes and segmental scleral buckling in 20 eyes. RESULTS: With UBM, ciliochoroidal detachment was detected in all eyes (100%) following scleral encircling and in 8 eyes (40.0%) following segmental scleral buckling. After scleral encircling procedure, the eyes with preoperatively bullous and wide retinal detachment showed a severe ciliochoroidal detachment and edema of the ciliary body. Shallowing of the anterior camber occurred in all 11 eyes (100%) after scleral encircling and in 12 of 20 eyes (60.0%) after segmental scleral buckling. Marked shallowing with closure of the angle and elevated intraocular pressure occurred in 2 eyes. CONCLUSION: The results showed that careful postoperative examinations for the anterior segments, chamber angle, and intraocular pressure are necessary with slit-lamp examination and applanation tonometry after scleral buckling surgery.     

Retinal thickening after successful surgery for macula-off retinal detachment

PURPOSE: To study changes in retinal thickness after reattachment of the retina after scleral buckling surgery for rhegmatogenous retinal detachment. METHODS: In this retrospective study, patients were classified into three subgroups according to preoperative macular status. Retinal thickness within 3 mm of the center was measured with optical coherence tomography. RESULTS: Foveal retinal thickness at a mean of 2 years postoperatively was significantly increased in patients with preoperatively detached macula. Additionally retinal thickness in the fovea and postoperative visual acuity was positively correlated. CONCLUSIONS: Successful surgery for macula-off retinal detachment is associated with significant thickening of the neurosensory retina when examined with optical coherence tomography 6 months postoperatively.     

外路手术治疗陈旧性裂孔性视网膜脱离

目的 探讨外路手术治疗陈旧性裂孔性视网膜脱离的疗效,分析陈旧性裂孔性视网膜脱离的临床特点.方法 陈旧性裂孔性视网膜脱离34例(34只眼),在双目间接检眼镜直视下行裂孔及变性区定位,在裂孔及变性区周围行视网膜冷凝后,根据情况分别采用巩膜表面加压术、环扎术或环扎加压术.术后定期观察视力、玻璃体及视网膜复位情况.结果 ①随访1～6个月,术后视网膜裂孔封闭,完全复位28只眼,再脱离6只眼,均发生在手术后1个月;其中2例手术后不足10d再脱离.②视力情况:视力提高28只眼,矫正视力＜0.3者18只眼,≥0.3者10只眼.③视网膜下液吸收情况:3d完全吸收19例,6d完全吸收7例,3～4周吸收2例.④冷凝反应:Ⅰ级10只眼,Ⅱ级14只眼,Ⅲ级4只眼.结论 在双目间接检眼镜直视下,外路手术治疗陈旧性裂孔性视网膜脱离的手术效果良好,值得临床推广.手术后视网膜的复位和视力与病程有密切关系.陈旧性裂孔性视网膜脱离多是因为早期的误诊造成,应引起临床医生注意.     

Macular microcirculation blood flow changes after conventional surgery for rhegmatogenous retinal detachment

PURPOSE: To assess the macular microcirculation blood flow in patients after conventional surgery for rhegmatogenous retinal detachment (RRD) with Doppler laser scanning (HRF--Heidelberg retinal flowmeter). MATERIAL AND METHODS: Thirty patients (13 males and 17 females) in age: 28-68 years, mean age: 58.7 years with unilateral RRD without macular involvement were included in a prospective study. According to the type of buckling procedure the patients were divided into 3 groups: I--encircling band (8 cases), II--encircling band with radial or circumferential buckling (12 cases), III--radial or circumferential buckling (10 cases). In all patients the macular blood flow was measured with Heidelberg retina flowmeter (HRF) before and 4 weeks after scleral buckling procedures. Control group consists of the fellow eyes. RESULTS: At the baseline examination in a group of eyes with RRD the mean values of macular blood flow were significantly lower comparing to fellow eyes and reached respectively: 298.4 +/- 79.2 AU and 435.6 +/- 121.0 AU (p=0.001) and correlated with the extent of RRD (p<0.05). Four weeks after surgery eyes that underwent the buckling procedures showed the elevation of macular blood flow as compared to the baseline values (p=0.001), however they remain slightly lower as compared to fellow eyes. The macular microcirculation blood flow changes were not influenced by the type of scleral buckling (p=0.2). CONCLUSIONS: In the eyes with rhegmatogenous retinal detachment without macular involvement the mean macular microcirculation blood flows were lower as compared to fellow eyes. Different buckling procedures for rhegmatogenous retinal detachment influence the macular blood flow, causing its improvement as compared to the preoperative status but they remain lower comparing to fellow eyes.     

Primary 23-gauge vitreoretinal surgery for rhegmatogenous retinal detachment

AIM: To report the effectiveness and safety of primary 23-Gauge (G) vitreoretinal surgery for rhegmatogenous retinal detachment (RRD). METHODS: In this retrospective study, 49 eyes of 49 consecutive patients who underwent primary 23-G transconjunctival sutureless vitrectomy (TSV) for RRD between January 2007 and July 2009 at our institution were evaluated. RESULTS: Mean follow-up time was 8.9±7.7 months (1-28 months). Retinal reattachment was achieved with a single operation in 47(95.9%) of 49 eyes. In two eyes (4.1%), retinal redetachment due to new breaks was successfully treated with reoperation using the 23-G TSV system. Mean logMAR visual acuity was 2.01±0.47 preoperatively and 1.3±0.5 postoperatively (P<0.001, Paired t-test). Mean preoperative intraocular pressure (IOP) was 14.1±2.8mmHg. Mean postoperative IOP was 12.3±3.6mmHg at 1 day, 13.1±2.1mmHg at 1 week, 14.3±2.2mmHg at 1 month. Iatrogenic peripheral retinal break was observed in 1 eye (2.0%) intraoperatively. No sutures were required to close the scleral or conjunctival openings, and no eyes required convertion of surgery to 20-G vitrectomy. CONCLUSION: Primary 23-G TSV system was observed to be effective and safe in the treatment of RRD.     

球形孔源性视网膜脱离手术治疗的临床研究

目的 探讨用改良的放液、玻璃体腔注气、冷凝、加压(drain-air-cryotherapy-explants,DACE)的手术方式治疗球形孔源性视网膜脱离(bullous rhegmatogenous retinal detachment,BRRD)的疗效.方法 回顾性分析原发性BRRD首次行视网膜脱离手术的患者共38例38只眼.实验组22例22只眼采用改良DACE方式:采用先放液,玻璃体腔注气,再定位冷凝,加压或联合环扎的手术步骤.注气采用玻璃体切割仪注气装置.对照组16例16只眼行常规步骤巩膜扣带术(scleralbucking,SB):采用先定位冷凝,再放液加压或联合环扎的步骤.随访3-6个月,应用spss13.0统计软件包进行分析,采用四格表Fisher确切概率法(Fisher,sexact probabilities in 2×2 table)检验.以a=0.05为检验水准.结果 一次性手术视网膜复位率及最终复位率,实验组90.9%(20/22)和100.0%(22/22),对照组87.5%(14/16)和93.8%(15/16),差异无统计学意义(P=-1.000及P=0.421);定位裂孔准确率实验组95.5%(21/22),对照组62.5%(10/16).差异有统计学意义(P=0.028);术后最佳矫正视力提高率实验组77.3%(17/22).对照组56.3%(9/16),差异无统计学意义(P=0.289);术后并发症,新裂孔形成及白内障见于实验组,视网膜皱褶及PVR形成进展见于对照组.结论 改良DACE手术方式是治疗上方BRRD安全、有效的方法,可获得满意的手术成功率和较少的并发症.具有术中眼压相对稳定,定位裂孔准确,冷凝精确等特点.