Dr. SUBHADRA JALALI

Dr. KOMAL AGARWAL, Dr.AKASH BELENJE, Dr. KOMAL AGARWAL

Abstract

Purpose: To report short term treatment outcomes of a novel technique of combined scleral buckle with modified scleral imbrication for childhood onset complex retinal detachments

Methods: Retrospective analysis of 24 eyes. The surgical technique included modified scleral imbrication, combined with encircling band with or without a buckle (tire). Anatomical outcome at the last follow up was assessed.

Results: Mean age at time of surgery was 6 years (3 months -14 years). Most common primary etiology was ROP (17 eyes). Most common type of detachment included rhegmatogenous with tractional component (13 eyes). Retina showed complete attachment with no progression in 19 eyes (79%). No postoperative complication was noted.

Conclusions: The novel technique provided a new way of managing complex childhood onset retinal detachments with a single surgery, that otherwise require multiple vitreoretinal procedures often with unpredictable outcomes. Long-term outcomes are awaited.

Full Text  

Short term outcomes of combined buckle and scleral imbrication for childhood onset complex retinal detachments

Introduction:

Retinal detachment in children pose different challenges due to different anatomy, characteristics of the vitreous and associated ocular and systemic conditions. Due to tight adhesions between the vitreous and the retinal surface, no posterior vitreous detachment, higher chances of PVR; anatomical success rates of vitrectomy (62-88%) aren’t as good as that in adults.1 Scleral buckle is hence considered a first choice as there is minimal vitreous manipulation, less cataract formation and avoids the need of tamponade and positioning. However, scleral buckle is reserved for cases without significant PVR and other ocular anomalies. In cases of complex retinal detachment like those with a combined mechanism of retinal folds, traction and rhegma, the success rates with scleral buckle and PPV is poor.

Scleral imbrication was described first in 1958 as the primary procedure for repairing retinal detachment before vitrectomy was invented.2 With the advent of procedures like buckle and vitrectomy, imbrication was no longer done primarily in retinal detachment. Recently, imbrication was used to correct myopic foveoschisis and myopic macular hole with the thought that scleral shortening caused by imbrication causes the hole to close and schisis to collapse.3,4 With the same principle we used modified scleral imbrication ( imbrication with scleral buckle ) to manage complex retinal detachment in children where in the surgeon’s view buckle and/or vitrectomy would have poor anatomical results.

Methods:

It was a retrospective, interventional study of children (<16 years) presenting with complex retinal detachment. The study was conducted at a tertiary eye care institute in South India between October 2020 to December 2021. The study adhered to the declaration of Helsinki and was approved by the institutional review board. All the surgeries were done by a single surgeon.

Demographic details including age, gender and the eye involved was noted. Pre-operative primary and secondary diagnosis, pre-operative best corrected visual acuity (BCVA), fundus findings were evaluated. All patient underwent ancillary testing like wide field fundus photography or ultrasonography whenever deemed necessary.

Surgical technique

Diagnosis was confirmed and rhegma was tried to be located under general anesthesia on table before proceeding with surgery. Once the decision of scleral imbrication was taken, 360 degrees conjunctival peritomy was done and four recti were tagged. Rhegma or site of suspected rhegma was located and appropriate buckle was chosen. Site of imbrication was decided on the basis of site of rhegma and the extent of retinal detachment. Subretinal external drainage was done either with needle or using cutdown technique. Buckle was then placed and After a betadine wash of all quadrants, the conjunctiva was closed with 7-0 vicryl. Post-operative retinal status was evaluated. Descriptive statistics was used for analysis.

Results:

24 eyes of 24 patients were included in the study. Fifteen patients (62.5%) were male. Mean age at surgery was 47.1 months. Retinopathy of prematurity of was the most common primary diagnosis causing retinal detachment in 17 of the 24 eyes (70.8%). Eleven of 24 eyes (45.8%) had combined tractional and rhegmatogenous RD, nine (37.5%) had tractional RD and 4 (16.6%) had complex rhegmatogenous RD with PVR. 17 eyes (70.8%) had pre-operative retinal drag and fixed folds.

Imbrication was done in all eyes. Mean number of quadrants imbricated was 2.5 (median = 2). Additional buckle was used in all patients. Twenty one eyes (87.5%) had responded well to the surgery and 19 eyes (79%) had completely attached retina/settled retinal folds without progression post surgery. Failure of the surgery was seen in 3 eyes (12.5%) out of which 1 eye had recurrence causing the need for pars plana vitrectomy. Mean follow up was 197.8 days.

Discussion:

Our data showed that the anatomical success rate of scleral imbrication with buckle in complex retinal detachment of childhood onset is good (87.5%). The surgical success rates in pediatric RD with one surgery is much lower than adults and varies between 52 -78%.1 As a result, multiple surgeries might be required. Anatomical success after multiple interventions is still poor and ranges between 60-83%. This is much poorer in complex RD’s where additional tractional component or the presence of retinal folds makes vitrectomy extremely difficult. Scleral buckle in such cases might not provide adequate reversal of forces to close the rhegma or flatten the progressing retinal folds. Scleral imbrication provides additional scleral shortening and hence aiding in reversing vector forces for retinal re-attachment.

The study is however, limited due its retrospective nature and lack of comparative arm. The sample size is small. We evaluated only the short term outcomes and the long term follow up of the technique is awaited.

Conclusion:

To conclude, scleral imbrication with scleral buckle shows encouraging short term anatomical results in childhood onset complex retinal detachment. The novel technique provided a new way of managing complex childhood onset retinal detachments with a single surgery, that otherwise require multiple vitreoretinal procedures often with unpredictable outcomes. Long-term outcomes are awaited.

References:

1. Al Abdulsalm O, Al Habboubi H, Mura M, Al-Abdullah A. Re-Vitrectomy versus Combined Re-Vitrectomy with Scleral Buckling for Pediatric Recurrent Retinal Detachment. Clin Ophthalmol. 2022 Mar 22;16:877-884
2. SWAN KC. Scleral imbrication for retinal detachment. AMA Arch Ophthalmol. 1959 Jan;61(1):110-4
3. Ando Y, Hirakata A, Ohara A, Yokota R, Orihara T, Hirota K, Koto T, Inoue M. Vitrectomy and scleral imbrication in patients with myopic traction maculopathy and macular hole retinal detachment. Graefes Arch Clin Exp Ophthalmol. 2017 Apr;255(4):673-680
4. Fujikawa M, Kawamura H, Kakinoki M, Sawada O, Sawada T, Saishin Y, Ohji M. Scleral imbrication combined with vitrectomy and gas tamponade for refractory macular hole retinal detachment associated with high myopia. Retina. 2014 Dec;34(12):2451-7