Purpose
To determine risk factors of choroidal detachment after scleral buckling procedure for treatment of retinal detachment.
Design
Retrospective chart review.
Methods
The authors performed a retrospective study of 69 consecutive cases of retinal detachment from January 2007 to January 2008 treated by scleral buckling surgery. Two groups of patients were defined according to the absence or apparition of choroidal detachment, and a comparison of several parameters between these 2 groups was performed.
Results
Fifteen patients developed a choroidal detachment. The study found an average higher level of systolic blood pressure during surgery in the group with choroidal detachment than in the absence group (127.3 vs 119.1 mm Hg; P = .008). The authors also observed a statistically significant difference between the 2 groups when comparing the intraoperative peak value of systolic blood pressure (149.3 vs 138.5 mm Hg; P = .019). Finally, in the group that developed choroidal detachment, there were statistically more patients with high myopia ( P = .02).
Conclusion
This study highlights that the 2 main risk factors for development of choroidal detachment during scleral buckling surgery are high blood pressure during the intervention and the existence of high myopia.
Rhegmatogenous retinal detachment occurs in 0.3% of the emmetropic population, but the prevalence increases in myopic or pseudophakic patients. Without a rapid treatment the entire retina may detach, leading to vision loss and blindness. The main objectives of treatment are to create a chorioretinal scar at the site of the retinal tear and to mechanically appose the detached sensory retina to the underlying retinal pigment epithelium. This apposition is achieved by means of scleral buckling or intraocular tamponade. In scleral buckling the eye wall is indented under the retinal tear with a silicone buckling element. The band pushes the wall of the eye inward against the retinal hole, closing the hole and allowing the retina to reattach. The surgical success rates of this procedure are quite high with just 1 operation, especially when the retinal detachment is not complex.
Nonetheless, despite the anatomic efficacy and the simplicity of this procedure, scleral buckling poses some short-term and long-term risks. Complications and side effects arising from this technique include refractive changes, infection, intrusion or extrusion of the buckling element, strabismus, glaucoma, macular edema, choroidal detachment, and persistent ocular pain. Choroidal detachment is the most common complication, occurring in 23% to 44% of cases. It may be classified as serous, sero-sanguinous, or hemorrhagic detachment. The exact triggering mechanism of this complication is unknown. Nevertheless, it is usually self-limited and spontaneously resolved in approximately 2 weeks. In some cases it can lead to severe visual loss.
In summary, choroidal detachment secondary to buckling surgery represents a frequent complication that can be associated with visual loss. Thus, the aim of this study is to determine risk factors of choroidal detachment after scleral buckling procedure in order to improve treatment of patients who present these conditions.
Material and Methods
Patient Selection
We performed a retrospective chart review of 69 consecutive cases of retinal detachment between January 2007 and January 2008 treated by scleral buckling procedure. Our patients comprised 22 women and 47 men whose ages ranged from 18 to 79 years (mean: 56.1). All cases were rhegmatogenous retinal detachments. Sixty-four patients (92.8%) had spontaneous rhegmatogenous retinal detachment and the remainder had rhegmatogenous retinal detachments associated with a history of antecedent trauma. One patient presented a complicated persistent retinal detachment and had undergone 1 previous vitreoretinal surgical procedure with scleral buckling. Twenty-four patients had high myopia (more than 6 diopters).
Surgical Technique
All surgeries were performed by 2 experienced vitreoretinal surgeons using general anesthesia in 91.3% of cases (63 patients) and peribulbar anesthesia in 8.7% of cases (6 patients). Trans-scleral drainage of subretinal fluid with a Vicryl (Ethicon, San Angelo, Texas, USA) 8/0 needle was made in all cases. We never observed any subretinal hemorrhage at the time of subretinal drainage. Breaks were treated with trans-scleral cryoretinopexy under microscopic visualization and buckling elements were carefully sutured to the superficial sclera with 5.0 Dacron (Ethicon) mattress sutures. There was no case of deep suture passes. We used 4 widths of silicone band (asymmetrical tire measuring 7 mm, 9 mm, 10 mm, and 12 mm; FCI Ophthalmics, Marshfield Hills, Massachusetts, USA) according to the localization of the break and the length of the silicone band depended on the number of retinal breaks or, for pseudophakic patients, on the number of quadrants detached. During surgery, no vortex veins were damaged, no rectus muscles were removed, and no cases of hypotonia were observed.
Analysis
For all patients, ophthalmologic evaluation included width and length of silicone band used, postoperative intraocular pressure, and the apparition of choroidal detachment during sugery or during the first 3 postoperative days. General evaluation was represented by arterial blood pressure measurement (systolic and diastolic) during surgery. For each patient, we retained for analysis the peak value of systolic and diastolic blood pressure and we calculated the mean systolic and diastolic blood pressure. We also collected the medical histories of all patients, especially if there was arterial hypertension, and we noted the treatment usually taken by patients, especially when it came to antiplatelet or anticoagulant.
We defined 2 groups of patients according to the apparition of choroidal detachment during surgery or during the first 3 postoperative days: the group “with choroidal detachment” represents cases with choroidal detachment and the group “without choroidal detachment” represents cases not complicated by choroidal detachment. Then, we performed a comparison of several parameters between these 2 groups. The principal outcome analyzed was the level of systolic arterial blood pressure during surgery. The secondary outcomes were diastolic arterial blood pressure during surgery, width and length of silicone band used, the existence of myopia, the medical history of arterial hypertension, type of anesthesia used, intraocular pressure during the 3 postoperative days, extent of retinal detachment, gender, sex ratio, and the receipt of antiplatelet or anticoagulant treatment. Concerning width and length of the scleral buckle element, to facilitate analysis, we considered 4 categories of patients: patients with silicone band measuring 10 mm or more, patients with silicone band measuring 9 mm or less, patients with scleral buckling superior to 180 degrees, and patients with scleral buckling inferior to 180 degrees.
Qualitative values were compared by the Fisher exact or χ 2 test. The comparison of quantitative variables was performed using the Mann-Whitney test. Statistical analyses were done with SPSS software for Windows (SPSS Inc, Chicago, Illinois, USA). A P value <.05 was considered to indicate a significant difference.
Results
In this study we included 69 consecutive cases of retinal detachment treated by scleral buckling surgery. Most cases (98.6%, 68 patients) were represented by partial retinal detachment. Two patients had undergone 1 vitreoretinal surgical procedure with scleral buckling. In these cases retinal detachment was caused by a new retinal break in a part of the retina untreated during the first procedure.
We obtained for each patient all the information needed for the analysis. The number of average blood pressure measurements taken during intervention was 15. The follow-up was at least 3 days after surgery. An ophthalmologic visit with a fundus examination was performed each day after the intervention for at least 3 days in order to detect early choroidal detachment. All patients with choroidal detachment (serous, sero-sanguinous, or hemorrhagic detachment) during surgery or in the first 3 days postoperatively were included in the “with choroidal detachment” group.
We observed the apparition of choroidal detachment for 15 of 69 (21.7%) patients (5 sero-sanguinous hemorrhagic detachments and 10 hemorrhagic detachments). So, for the analysis we included 15 patients in the “with choroidal detachment” group and 54 patients in the “without choroidal detachment” group. The development of choroidal detachment occurred during surgery in 1 case and during the first 2 postoperative days in the other cases. All patients with a choroidal detachment received combination therapy with corticosteroids (topical and systemic) and acetazolamide. It has never been necessary to resort to surgical treatment.
Principal Outcome
Concerning the principal outcome, which was intraoperative systolic arterial blood pressure, we found an average level higher in the “with choroidal detachment” group than in the “without choroidal detachment” group (127.3 mm Hg vs 119.1 mm Hg, P = .008). We also noted a statistically significant difference between the 2 groups when we compared the intraoperative peak value of systolic blood pressure (149.3 mm Hg vs 138.5 mm Hg, P = .019).
Secondary Outcomes
For diastolic blood pressure we observed a similar difference, but only for the intraoperative peak value (90 mm Hg vs 80 mm Hg, P = .019). We did not note a statistically significant difference for the mean level of diastolic pressure. Concerning refractory status, there were statistically more patients with high myopia in the “with choroidal detachment” group ( P = .02).
There was no statistically significant difference concerning intraocular pressure during the 3 postoperative days; in particular, we did not observe any cases of ocular hypotonia in the “with choroidal detachment” group during or after surgery. The analysis of width and length of silicone band used did not highlight any difference between the 2 groups. Indeed, in the group of patients whose surgery was complicated by a choroidal detachment we did not note a greater number of scleral buckle elements measuring 180 degrees or more or 10 mm or more. Medical history of arterial hypertension and number of patients taking antiplatelet or anticoagulant treatments were not different between the “with choroidal detachment” group and the “without choroidal detachment” group. Concerning gender, age, lens status, extent of retinal detachment, and type of anesthesia (general or local), we also did not find any differences.
The comparison between the 2 groups for all parameters is presented in the Table .
| Group With Choroidal Detachment (n=15) | Group Without Choroidal Detachment (n=54) | P Value | |
|---|---|---|---|
| Mean of systolic blood pressure | 127.3 mm Hg | 119.1 mm Hg | .008 |
| Peak value of systolic blood pressure | 149.3 mm Hg | 138.5 mm Hg | .019 |
| Mean of diastolic blood pressure | 72.9 mm Hg | 67.6 mm Hg | NS |
| Peak value of diastolic blood pressure | 90 mm Hg | 80 mm Hg | .019 |
| Medical history of hypertension | 5 | 14 | NS |
| Patients with high myopia | 9 | 15 | .02 |
| Lens status | |||
| – Phakic | 14 | 52 | NS |
| – Pseudophakic | 1 | 2 | |
| Extent of retinal detachment | |||
| – Total retinal detachment | 1 | 0 | NS |
| – Partial retinal detachment | 14 | 54 | |
| Mean IOP during the first 3 days postoperatively | 18 | 19 | NS |
| Encircling buckle | 2 | 2 | NS |
| Scleral buckling superior ≥180 degrees | 10 | 23 | NS |
| Scleral buckling inferior <180 degrees | 5 | 30 | NS |
| Asymmetrical tire ≥10 mm | 8 | 17 | NS |
| Asymmetrical tire ≤9 mm | 7 | 37 | NS |
| General anesthesia | 15 | 48 | NS |
| Local anesthesia | 0 | 6 | NS |
| Antiplatelet or anticoagulant treatment | 2 | 5 | NS |
| Age of patients | 55.73 | 56.39 | NS |
| Sex ratio (M/F) | 13/2 | 34/20 | NS |
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