·Clinical Research··Current Issue· ·Achieve· ·Search Articles· ·Online Submission· ·About IJO· PMC
Predictive factors for postoperative
visual function of primary chronic rhegmatogenous retinal
detachment after scleral buckling
Wei Fang, Jiu-Ke Li, Xiao-Hong Jin, Yuan-Min
Dai, Yu-Min Li
Department of Ophthalmology, SIR RUN RUN SHAW Hospital, SIR RUN
RUN SHAW Institute of Clinical Medicine of Zhejiang University, Hangzhou
310016, Zhejiang Province, China
Correspondence to: Yu-Min
Li. Department of Ophthalmology, SIR RUN RUN SHAW Hospital,
SIR
RUN RUN SHAW Institute of Clinical Medicine of Zhejiang University, #3 Qingchun
East Road, Hangzhou 310016, Zhejiang Province, China.
liyumin77@hotmail.com
Received:
2015-03-31
Accepted: 2015-09-16
Abstract
AIM: To evaluate
predictive factors for postoperative visual function of primary chronic
rhegmatgenous retinal detachment (RRD) after sclera buckling
(SB).
METHODS: Totally 48
patients (51 eyes) with primary chronic RRD were included in this prospective
interventional clinical cases study, which underwent SB alone from June 2008 to
December 2014. Age, sex,
symptoms duration, detached extension, retinal hole position, size, type, fovea
on/off, proliferative vitreoretinopathy (PVR), posterior vitreous detachment
(PVD), baseline best corrected visual acuity (BCVA), operative duration, follow
up duration, final BCVA were measured. Pearson
correlation analysis, Spearman correlation analysis and multivariate linear
stepwise regression were used to confirm predictive factors for better final
visual acuity. Student’s t-test,
Wilcoxon two-sample test, Chi-square test and logistic stepwise regression were
used to confirm predictive factors for better vision improvement.
RESULTS: Baseline BCVA
was 0.8313±0.6911 logMAR and final BCVA was 0.4761±0.4956
logMAR. Primary surgical success rate was 92.16% (47/51). Correlation analyses
revealed shorter symptoms duration (r=0.3850,
P=0.0053), less detached area (r=0.5489, P<0.0001), fovea (r=0.4605,
P=0.0007), no PVR (r=0.3138, P=0.0250), better baseline BCVA (r=0.7291, P<0.0001),
shorter operative duration (r=0.3233,
P=0.0207) and longer follow up (r=-0.3358, P=0.0160) were related with better final BCVA, while independent
predictive factors were better baseline BCVA [partial R-square (PR2)=0.5316,
P<0.0001], shorter symptoms
duration (PR2=0.0609, P=0.0101),
longer follow up duration (PR2=0.0278, P=0.0477) and shorter operative duration (PR2=0.0338, P=0.0350). Patients with vision
improvement took up 49.02% (25/51). Univariate and multivariate analyses both
revealed predictive factors for better vision improvement were better baseline
vision [odds ratio (OR) =50.369, P=0.0041]
and longer follow up duration (OR=1.144, P=0.0067).
CONCLUSION:
Independent predictive factors for better visual outcome of primary chronic RRD
after SB are better baseline BCVA, shorter symptoms duration, shorter operative
duration and longer follow up duration, while independent predictive factors
for better vision improvement after operation are better baseline vision and
longer follow up duration.
KEYWORDS: chronic retinal
detachment; scleral buckling; predictive factors
DOI:10.18240/ijo.2016.07.10
Citation: Fang
W, Li JK, Jin XH, Dai YM, Li YM. Predictive factors for postoperative visual
function of primary chronic rhegmatogenous retinal detachment after scleral
buckling. Int J Ophthalmol 2016;9(7):994-998
INTRODUCTION
Primary
chronic rhegmatogenous retinal detachment (RRD) usually occurs in young
patients, characterized by shallow detached retina, smooth retinal surface, and
mostly atrophic retinal hole. Primary chronic RRD rarely has obvious
intravitreous proliferation or vitreoretinal interface proliferation, and
rarely with complete posterior vitreous detachment (PVD)[1].
According to these clinical features scleral buckling (SB) is more eligible to
restore the detached retina. SB has been proved as a safe and effective method
in long-standing inferior RRD, RRD secondary to round retinal holes, and
chronic RRD with subretinal proliferation[2-5].
However prognostic factors for postoperative visual functions are rarely
reported in this type of RRD. So here in this paper we aimed to evaluate some
related factors predicting better final visual acuity and predicting better
vision improvement (compared with baseline vision of each patient) after SB
alone in primary chronic RRD.
SUBJECTS AND METHODS
Patient Group This study was
approved by SIR RUN RUN SHAW Hospital Ethic
Committee. Totally 48 patients (51 eyes) with primary chronic RRD undergoing SB
alone from June 2008 to December 2014 composed this cases group. All patients
have signed an informed consent, receiving no stipend. Inclusive criteria: 1)
no acute history of chief symptoms like vision loss or visual field defect; 2)
chief symptoms lasted more than 3mo and corresponded to the detached retina; 3)
fundus examination revealed detached retina with concentric demarcation lines
around retinal hole accompanied by retina thinning or fixed. All patients
meeting criterion 1+2 or 1+3 entered the study group. Recurrent RRD,
proliferative vitreoretinopathy (PVR) C3 or greater and acute RRD were
excluded. Demarcation lines should be differentiated from subretinal
proliferation. The latter appeared as irregular subretinal strands and elevated
the detached retina, like napkin rings formation, while demarcation lines
usually appeared as pigmented or depigmented concentric arcs around primary
retinal hole, not elevating the retina, which could to some degree restrict
expansion of subretinal fluid. All patients underwent encircling silicone band,
silicone sponge implant, cryocoagulation and subretinal fluid drainage. Radial
or circumferential segment implant was used due to retinal tear type[6].
Main Measures Age, sex,
symptoms duration, detached extension (involved quadrants), retinal hole
position, size (disk diameters, DD), type (tear or atrophic hole), number
(single or multiple), fovea on/off, PVR, PVD, baseline best-corrected visual
acuity (BCVA), operative duration, follow up duration, final BCVA. The main
hole which most corresponded with the detached retina was taken into account
when more than one retinal hole existed.
Definition of Vision Improvement
Visual
acuity improved 2 lines on Snellen chart or from handmovement to counting
fingers or counting fingers to more than 1/50, compared with baseline vision.
Definition
of Success Complete
anatomic retinal reattachment.
Statistical Analysis Pearson
correlation analysis, Spearman correlation analysis and multivariate linear
stepwise regression were used to confirm predictive factors for better final
visual acuity. Student’s t-test,
Wilcoxon two-sample test, Chi-square test and logistic stepwise regression were
used to confirm predictive factors for better vision improvement. Significant P value threshold was 0.05. Snellen
values were changed into logMAR values, and counting fingers were designated as
2 logMAR, handmovement as 3 logMAR. All of those analyses were done by software
SAS 9.1.3.
RESULTS
Totally
30 males and 18 females were enrolled in this group, with an average age of 27.71
years old (27.71±9.60y). Mean follow up duration
was 10mo (10.69±13.64mo). The detached retina covered about 1.84 quadrants (1.84±0.67
quadrants), with an average 0.86 DD retinal hole (0.86±1.14 DD), most of which
was atrophic hole (98.04%, 50/51) and located at lower half part of the fundus (76.47%,
39/51). Of 7 patients had fovea attached (13.73%, 7/51). No patient had
complete PVD. PVR took up 9.80% (5/51), all of which were subretinal
proliferation. Average operative duration was 69.02min (69.02±16.52min).
Baseline BCVA was 0.8314±0.6912 logMAR and final BCVA was 0.4761±0.4956 logMAR.
Primary surgical success rate was 92.16% (47/51). The remaining 4 patients had
a secondary vitrectomy (2 cases) or intravitreous C3F8 gas injection (2 cases),
eventually achieving a satisfactory retinal reattachment.
Pearson
correlation and Spearman correlation analyses revealed shorter symptoms
duration (r=0.3850, P=0.0053), less detached area (r=0.5489, P<0.0001), fovea (r=0.4605,
P=0.0007), no PVR (r=0.3138, P=0.0250), better baseline BCVA (r=0.7291, P<0.0001),
shorter operative duration (r=0.3233,
P=0.0207) and longer follow-up (r=-0.3358, P=0.0160) were related with better final BCVA (Table 1), while
independent predictive factors were better baseline BCVA (PR2=0.5316,
P<0.0001), shorter symptoms
duration (PR2=0.0609, P=0.0101),
longer follow-up duration (PR2=0.0278, P=0.0477) and shorter operative duration (PR2=0.0338, P=0.0350) (Table 2). Patients with
vision improvement took up 49.02% (25/51). Univariate and multivariate analyses
both revealed predictive factors for better vision improvement were better baseline
vision (OR=50.369, P=0.0041) and
longer follow up duration (OR=1.144, P=0.0067) (Tables 1, 3).
|
Variables |
|
BCVA |
Vision
improvment |
||
|
r |
P |
|
P |
||
|
Age
(a) |
27.71±9.60 |
-0.1438 |
0.3142a |
0.86 |
0.3926c |
|
Sex |
|
0.2077 |
0.1437b |
1.0711 |
0.3007d |
|
M |
30
(62.50) |
|
|
|
|
|
F |
18
(37.50) |
|
|
|
|
|
Symptoms
duration (mo) |
6.84±14.93 |
0.3850 |
0.0053a |
-0.1607 |
0.4362e |
|
Detached
extension (quadrants) |
|
0.5489 |
<0.0001b |
5.6492 |
0.1300d |
|
1 |
15
(29.41) |
|
|
|
|
|
2 |
30
(58.82) |
|
|
|
|
|
3 |
5
(9.8) |
|
|
|
|
|
4 |
1
(1.96) |
|
|
|
|
|
Retinal
hole position |
|
-0.1789 |
0.2092b |
3.6228 |
0.0570d |
|
Upper part |
12
(23.53) |
|
|
|
|
|
Lower part |
39
(76.47) |
|
|
|
|
|
Retinal
hole size (DD) |
0.86±1.14 |
-0.0745 |
0.6036b |
1.1801 |
0.2380e |
|
Retinal
hole type |
|
0.1017 |
0.4778b |
1.0608 |
0.3030d |
|
Tear |
1
(1.96) |
|
|
|
|
|
Atrophic hole |
50
(98.04) |
|
|
|
|
|
Retinal
hole number |
|
0.0325 |
0.8207b |
0.4727 |
0.4917d |
|
Single |
29
(56.86) |
|
|
|
|
|
Multiple |
22
(43.14) |
|
|
|
|
|
Fovea
status |
|
0.4605 |
0.0007b |
1.3575 |
0.2440d |
|
On |
7
(13.73) |
|
|
|
|
|
Off |
44
(86.27) |
|
|
|
|
|
PVR |
|
0.3138 |
0.0250b |
0.4008 |
0.8184d |
|
Yes |
5
(9.80) |
|
|
|
|
|
No |
46
(90.20) |
|
|
|
|
|
Baseline
BCVA (logMAR) |
0.8314±0.6912 |
0.7291 |
<0.0001a |
3.1512 |
0.0008e |
|
Operative
duration (min) |
69.02±16.52 |
0.3232 |
0.0207a |
1.03 |
0.3099c |
|
Follow
up duration (mo) |
10.69±13.64 |
-0.3358 |
0.0160a |
2.4052 |
0.0081e |
BCVA: Best-corrected visual acuity; PVR:
Proliferative vitreoretinopathy. aPearson correlation analysis; bSpearman
correlation analysis; cStudent’s t-test;
dChi-square test; eWilcoxon two-sample test. P value less than 0.05 was considered as
significant level.
Table
2 Multivariate linear stepwise regression of related factors predicting better
visual acuity
|
Variables |
PR2 |
MR2 |
P |
|
Baseline BCVA |
0.5316 |
0.5316 |
<0.0001 |
|
Symptoms duration |
0.0609 |
0.5925 |
0.0101 |
|
Follow up duration |
0.0278 |
0.6203 |
0.0477 |
|
Operative duration |
0.0338 |
0.6541 |
0.0350 |
PR2:
Partial R-square; MR2: Model R-square.
Table
3 Logistic stepwise regression of related factors predicting better vision
improvement
|
Variables |
B |
SE |
OR |
95%CI |
P |
|
Baseline
BCVA |
3.9194 |
1.3648 |
50.369 |
3.471-730.996 |
0.0041 |
|
Follow
up duration |
0.1344 |
0.0496 |
1.144 |
1.038-1.261 |
0.0067 |
B: B
value; SE: Standard error; OR: Odds ratio; CI: Confidential interval.
DISCUSSION
Many
studies had described the predictive factors for functional outcomes of primary
RRD after operation. Baseline BCVA, symptoms duration, fovea status, detached
extension and PVR had been confirmed as the related variables whether through
SB or vitrectomy, and baseline BCVA was even considered the most important
valuable[7-12]. Similar to those studies,
we also found those factors associated with better postoperative visual acuity
in primary chronic RRD group by correlation analysis. But during multivariate
analysis process some factors like fovea status, detached extension and PVR
were excluded. We explained that they were eliminated because of association
significantly with baseline BCVA (fovea status, r=0.5541, P<0.0001;
detached extension, r=0.6292, P<0.0001;
PVR, r=0.3238, P=0.0204; Spearman correlation analysis), so baseline BCVA might be
a better independent surrogate of those factors. However unlike previous
studies, we found follow up duration and operative duration were the
independent predictive factors for postoperative visual function, which had
been rarely reported before. Liu et al[13] observed long-term postoperative
vision improvement in macula-off primary RRD after SB. They revealed that even
5-10y after surgery, visual acuity was still improving, which suggested that
the reconstruction process of retinal synapse and functional recovery could
last a very long period, corresponding with our study. Some studies found that
postoperative subretinal fluid usually occured in long-standing retinal
detachment, and some of which might spontaneously resolve at a long period
follow up with vision improved[14-16]. Though
we have not evaluated the subretinal fluid condition in this study, it might
also to some degree contribute to persistent vision improvement here
accordingly. Besides, we found longer operative duration of SB could lead to
lower postoperative vision, though exactly reason were not found so far, we
suggested shortening operative time during treatment might be more beneficial
for patients.
For
each patient his/her self, the most cared was how much he/she could benefit
from the treatment. So in this study, we compared the final BCVA with baseline
BCVA and found that about a half of patients were satisfied with their vision improvement.
While only two factors confirmed were associated with vision improvement:
baseline BCVA and follow up duration, and the former was much more important
(OR=50.369, 95%CI 3.471-730.996). It meant that baseline BCVA might not only
mainly affect the final visual function of reattached retina on total group
level, but also determine the recovery potential of the impaired retina of each
patient, and so was the factor follow up duration, which might be a little helpful
in our clinical activities.
In
primary chronic RRD, most patients could not remember exactly the onset of
symptoms, and usually the impaired eye was found occasionally, so retinal
detachment duration might be much longer than symptoms duration. As we all know,
during the first day of retinal detachment many types of cells like polymorphonuclear neutrophils,
monocytes, and macrophages migrate from the choroidal and retinal capillaries into
subretinal space, and free retinal pigment epithelium cells are also seen in
the subretinal space within 72h, containing outer-segment fragments frequently,
which indicates that they may play a role in phagocytosis of cellular debris. Several
days after retinal detachment, the inner segments begin to show signs of
degeneration: swelling, disruption, loss of mitochondria, and overall
disruption of the organized rough endoplasmic reticulum and Golgi apparatus,
but it is interesting to note that the connecting cilium (essential for
production of the outer segment) is retained even in severely affected inner
segments in long-term detachments. As in monkey retinas detached for 1wk, rod
and cone outer segments regain approximately 30% of their normal mean length
within 7d of reattachment, 60% of their length after 30d, and 100% by 150d. Though
all those data are collected from animal experiments, they are comparable with cellular
changes in some human retinal detachment specimen analysis after vitreoretinal
surgery, which may explain the relatively good regeneration of outer segments
and render a long time vision improvement following reattachment[17]. Besides, in this study of primary
chronic RRD, despite of long retinal detachment duration and detached retina
thinning or fixed, there was an excellent success rate (92.16%), similar to
others’ studies, so SB is a good choice for this type of RRD[4-5,18-21].
In
conclusion, independent predictive factors for better visual outcome of primary
chronic RRD after SB are better baseline BCVA, shorter symptoms duration,
shorter operative duration and longer follow up duration, while independent
predictive factors for better vision improvement after operation are better
baseline vision and longer follow up duration.
ACKNOWLEDGEMENTS
Conflicts
of Interest: Fang W, None; Li JK, None; Jin XH, None;
Dai YM, None; Li YM, None.
REFERENCES
1
Li YM, Fang W, Jin XH, Li JK, Zhai J, Feng LG. Risk factors related to chronic
rhegmatogenous retinal detachment. Int J
Ophthalmol 2012;5(1):92-96.
2 Alexander P, Ang A, Poulson A, Snead MP. Scleral buckling
combined with vitrectomy for the management of rhegmatogenous retinal
detachment associated with inferior retinal breaks. Eye (Lond) 2008;22(2):200-203. [CrossRef] [PubMed]
3 Ung T, Comer MB, Ang AJ, Sheard R, Lee C, Poulson AV, Newman DK,
Scott JD, Richards AJ, Snead MP. Clinical features and surgical management of
retinal detachment secondary to round retinal holes. Eye (Lond) 2005;19(6):665-669. [CrossRef] [PubMed]
4 Yao Y, Liang L, Wang ZJ, Zhang MN. Scleral Buckling Procedures
for Longstanding or Chronic Rhegmatogenous Retinal Detachment with Subretinal
Proliferation. Ophthalmology
2006;113(5):821-825. [CrossRef]
[PubMed]
5 Ozdek S, Kilic A, Gurelik G, Hasanreisoglu B. Scleral buckling
technique for longstanding inferior rhegmatogenous retinal detachments with
subretinal bands. Ann
Ophthalmol (Skokie) 2008;40(1):35-38.
6 Ho CL, Chen KJ, See LC. Selection of scleral buckling for
primary retinal detachment. Ophthalmologica
2002;216(1):33-39. [CrossRef]
7 Heussen N, Feltgen N, Walter P, Hoerauf H, Hilgers RD, Heimann
H, SPR Study Group. Scleral buckling versus primary vitrectomy in
rhegmatogenous retinal detachment study (SPR Study): predictive factors for
functional outcome. Study report no. 6. Graefes
Arch Clin Exp Ophthalmol 2011;249(8):1129-1136. [CrossRef] [PubMed]
8 de Silva DJ, Kwan A, Bunce C, Bainbridge J. Predicting visual
outcome following retinectomy for retinal detachment. Br J Ophthalmol 2008;92(7):954-958. [CrossRef] [PubMed]
9 Pastor JC, Fernández I, Rodríguez de la Rúa E, Coco R,
Sanabria-Ruiz Colmenares MR, Sánchez-Chicharro D, Martinho R, Ruiz Moreno JM,
García Arumi J, Suárez de Figueroa M, Giraldo A, Manzanas L. Surgical outcomes
for primary rhegmatogenous retinal detachments in phakic and pseudophakic
patients: the Retina 1 Project-report 2. Br
J Ophthalmol 2008;92(3):378-382. [CrossRef] [PubMed]
10 Sharma YR, Karunanithi S, Azad RV, Vohra R, Pal N, Singh DV,
Chandra P. Functional and anatomic outcome of scleral buckling versus primary
vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand 2005;83(3):293-297. [CrossRef] [PubMed]
11 Williamson TH, Shunmugam M, Rodrigues I, Dogramaci M, Lee E.
Characteristics of rhegmatogenous retinal detachment and their relationship to
visual outcome. Eye (Lond) 2013;27(9):1063-1069.
[CrossRef] [PubMed] [PMC free article]
12 Suzuki N, Kunikata H, Aizawa N, Abe T, Nakazawa T. Predicting visual
outcomes for macula-off rhegmatogenous retinal detachment with optical
coherence tomography. J Ophthalmol
2014;2014:269837. [CrossRef]
[PubMed] [PMC free article]
13 Liu F, Meyer CH, Mennel S, Hoerle S, Kroll P. Visual recovery
after scleral buckling surgery in macula-off rhegmatogenous retinal detachment.
Ophthalmologica 2006;220(3):174-180.
[CrossRef] [PubMed]
14 Moreno-López M, Pérez-López M, Casas-Llera P, Jarrín E,
Muñoz-Negrete FJ. Persistent subretinal fluid due to central serous
chorioretinopathy after retinal detachment surgery. Clin Ophthalmol 2011;5:1465-1467. [CrossRef] [PubMed] [PMC free article]
15 Veckeneer M, Derycke L, Lindstedt EW, van Meurs J, Cornelissen
M, Bracke M, Van Aken E. Persistent subretinal fluid after surgery for
rhegmatogenous retinal detachment: hypothesis and review. Graefes Arch Clin Exp Ophthalmol 2012;250(6):795-802. [CrossRef] [PubMed]
16 Lin W, Pan CK, Tsui I. Spontaneous resolution of clinically
apparent submacular fluid after scleral buckling surgery. Ophthalmic Surg Lasers Imaging Retina 2014;45(5):474-477. [CrossRef] [PubMed]
17 Wickham L, Lewis GP, Charteris DG, Fisher SK. Cellular Effects
of Detachment and Reattachment on the Neural Retina and the Retinal Pigment
Epithelium. In Ryan SJ, Editor-In-Chief. Retina.
5th ed. Elsevier. 2013;605-617. [CrossRef]
18 Sato T, Emi K, Bando H, Ikeda T. Retrospective comparison of
25-gauge vitrectomy for repair of proliferative vitreoretinopathy with or
without anterior proliferation. Graefes
Arch Clin Exp Ophthalmol 2014;252(12):1895-1902. [CrossRef] [PubMed]
19 Sharma H, Joshi SN, Shrestha JK. Anatomical and functional
outcomes of surgery of rhegmatogenous retinal detachment. Nepal J Ophthalmol 2010;2(2):132-137. [CrossRef]
20 Shankar V, Lim LT, Ah-Kee EY, Hammer H. Outcome of
rhegmatogenous retinal detachment repair by scleral buckling: The experience of
a tertiary referral center in Scotland. Oman
J Ophthalmol 2014;7(3):130-134. [CrossRef] [PubMed] [PMC free article]
21 Oluleye TS, Ibrahim O, Olusanya B. Scleral buckling for retinal
detachment in Ibadan, Sub-Saharan Africa: anatomical and visual outcome. Clin Ophthalmol 2013;7:1049-1052. [CrossRef] [PubMed] [PMC free article]