Surgical interventions for rhegmatogenous retinal detachments: alternatives to vitrectomy
Review question
We updated this review with the same aim of understanding which of the two surgical techniques, scleral buckle (SB) or pneumatic retinopexy (PR), is better for the treatment of certain types of rhegmatogenous retinal detachment (RRD).
Retinal detachment is the separation of the retina, the light-sensitive tissue at the back of the eye, from its underlying layer attached to the inner back surface of the eye. RRD is when the separation results from retinal breaks or tears, usually due to pulling (traction) from the vitreous, the substance that fills the center of the eye.
Three surgical interventions are used to repair the retinal break(s) in RRD: PR, SB, and vitrectomy. In PR, a gas bubble is injected into the vitreous cavity in the center of the eye to provide a mechanical seal (tamponade) for the retinal breaks until the breaks can be sealed with heat (laser) or cold (cryotherapy). In SB, local pressure is applied to retinal breaks by suturing material onto the outer part of the eye (sclera) to indent (buckle) it inward. In vitrectomy, the vitreous is removed to relieve traction on the retina from the vitreous and a gas, or silicon oil, may be used to facilitate healing.
Study characteristics
We found three randomized trials (where people were randomly put into one of two or more treatment groups) that enrolled 274 participants (276 eyes) from Ireland, the US, and Italy. All trials evaluated whether PR or SB was a better treatment for RRD. The study in the US (1989) had 196 participants with six months to two years of follow-up. The study in Ireland (1996) had 20 participants with five to 27 months of follow-up. The study in Italy (2021) enrolled 58 participants with 12 months of follow-up. The evidence is current to 10 March 2021.
Study funding sources
Studies were funded by the authors' institutions or unknown resources.
Results from the three studies suggested that SB may perform better or as well as PR in terms of reattachment rates and for reducing the risk of recurrence of detachment. Few ocular adverse events (eye-related side effects) occurred during either procedure, and differences in some adverse events occurring after the surgeries were very uncertain. More eyes in the SB group experienced cataract and a shift of refraction toward myopia (change to nearsightedness that may be a sign of developing cataract) than eyes in the PR group.
Quality of the evidence
The quality of the evidence was mostly low due to poor reporting of how the studies were done. Each study reported visual acuity (clarity or sharpness of vision) differently. None of the studies analyzed important outcomes such as quality of life or costs related to the treatments themselves.
Authors' conclusions:
The current update confirms the findings of the previous review. PR may result in lower rates of reattachment and higher rates of recurrence than SB, but carries a lower burden of postoperative complications. The effects of these two procedures on other functional outcomes and quality of life remain uncertain. The available evidence remains insufficient and of low quality.
Read the full abstract...
A rhegmatogenous retinal detachment (RRD) is a separation of the neurosensory retina from the retinal pigment epithelium caused by a full-thickness break associated with vitreous traction. While pneumatic retinopexy (PR), scleral buckle (SB), and vitrectomy are all well-received surgical interventions for eyes with RRD, their relative effectiveness has remained controversial.
To assess the effectiveness and safety of PR versus SB or PR versus a combination treatment of SB and vitrectomy for people with RRD and to summarize any data on economic measures and quality of life.
Search strategy:
We searched CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 3); Ovid MEDLINE; Ovid Embase; and four other databases on 11 March 2021. We used no date or language restrictions in the electronic searches for trials.
Selection criteria:
We included all randomized or quasi-randomized controlled trials comparing the effectiveness of PR versus SB (with or without vitrectomy) for eyes with RRD.
Data collection and analysis:
After screening for eligibility, two review authors independently extracted study characteristics, methods, and outcomes. We followed systematic review standards as set by Cochrane.
Main results:
In this update, we identified and included one new randomized controlled trial. Together with two trials from the 2015 version of the review, we included three trials (276 eyes of 274 participants) comparing the effectiveness of PR versus SB. None compared PR versus a combined treatment of SB and vitrectomy.
Of the three trials, one was a small study (published in 1996) with 20 participants (20 eyes) enrolled in Ireland and followed for a mean of 16 months; the second (published in 1989) included 196 participants (198 eyes) in the US followed for at least six months, and the third (published in 2021) was conducted in Italy and enrolled 58 participants (58 eyes) with a follow-up of 12 months. Overall, poor reporting quality resulted in unclear or high risks of bias.
We found low-certainty evidence that PR may achieve retinal reattachment slightly less often than SB (risk ratio [RR] 0.91, 95% confidence interval [CI] 0.81 to 1.02; I2 = 0%; 3 studies, 276 eyes). Eyes undergoing PR may also display a higher risk of recurrent retinal detachment (low-certainty evidence), but the RR estimates were very imprecise (RR 1.70, 95% CI 0.97 to 2.98; I2 = 0%; 3 studies, 276 eyes).
All three studies described the final visual acuity (VA) after the two procedures. However, the results were reported using different metrics and could not be combined. One study (196 participants) reported the proportion of eyes with a final VA of 20/40 or greater and favored PR (RR 1.31, 95% CI 1.04 to 1.65; low-certainty evidence), whereas in the 2021 study, both groups showed an improvement in final VA and there was no evidence of a difference between the two (mean difference [MD] −0.03, 95% CI −0.25 to 0.19; low-certainty evidence).
No study reported data on quality of life or economic measures.
Postoperative safety outcomes generally favored PR versus SB (low/very low-certainty evidence); however, there was considerable uncertainty regarding the risk of any operative ocular adverse events (RR 0.55 CI 0.28 to 1.11; 276 eyes), glaucoma (RR 0.31, 95% CI 0.01 to 7.46; 198 eyes), macular pucker (RR 0.65, 95% CI 0.20 to 2.11; 256 eyes), proliferative vitreoretinopathy (RR 0.94, 95% CI 0.30 to 2.96; 276 eyes), and persistent diplopia (RR 0.24, 95% CI 0.03 to 2.09; 256 eyes). Eyes undergoing PR experienced fewer postoperative cataract developments (RR 0.40, 95% CI 0.21 to 0.75; 153 eyes), choroidal detachments (RR 0.17, 95% CI 0.05 to 0.57; 198 eyes), and myopic shift (RR 0.03, 95% CI 0.01 to 0.10; 256 eyes).
Health topics:
Eyes & vision > Retinal disease (including age-related macular degeneration) > Retinal detachment
Sena DF, Kilian R, Liu S-H, Rizzo S, Virgili G
Primary Review Group:
Eyes and Vision Group
Sena DF, Kilian R, Liu S-H, Rizzo S, Virgili G. Pneumatic retinopexy versus scleral buckle for repairing simple rhegmatogenous retinal detachments. Cochrane Database of Systematic Reviews 2021, Issue 11. Art. No.: CD008350. DOI: 10.1002/14651858.CD008350.pub3.
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