Oman Journal of Ophthalmology

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 12  |  Issue : 2  |  Page : 84--87

The feasibility and efficacy of intraoperative laser retinopexy in scleral buckling surgery


Roshija Khanal Rijal1, Deepesh Mourya2,  
1 Department of Vitreo Retinal Services, Lumbini Eye Institute, Bhairahawa, Nepal
2 Department of Vitreo Retinal Services, Akhand Jyoti Eye Hospital, Patna, Bihar, India

Correspondence Address:
Dr. Roshija Khanal Rijal
Lumbini Eye Institute, Bhairahawa, Rupandehi
Nepal

Abstract

BACKGROUND: This study was performed to assess the feasibility and efficacy of intraoperative laser retinopexy in scleral buckling (SB) surgery. MATERIALS AND METHODS: This was a retrospective, noncomparative, and interventional study. Records of 25 patients who had undergone intraoperative laser retinopexy during SB were retrospectively analyzed. RESULTS: All patients were phakic and macula was off in all cases. Adequate intraoperative laser retinopexy was achieved in 22 (88%) patients, and 3 (12%) patients required additional postoperative laser. Retina was attached in all patients at 6-month follow-up. CONCLUSION: Intraoperative laser retinopexy can give comparable results to cryoretinopexy with lesser postoperative complications in SB surgery. Although further comparative studies are needed, this study establishes the feasibility of intraoperative laser retinopexy in SB which has never been described before in the literature as per our knowledge.



How to cite this article:
Rijal RK, Mourya D. The feasibility and efficacy of intraoperative laser retinopexy in scleral buckling surgery.Oman J Ophthalmol 2019;12:84-87


How to cite this URL:
Rijal RK, Mourya D. The feasibility and efficacy of intraoperative laser retinopexy in scleral buckling surgery. Oman J Ophthalmol [serial online] 2019 [cited 2020 Nov 25 ];12:84-87
Available from: https://www.ojoonline.org/text.asp?2019/12/2/84/259695


Full Text



 Introduction



There are three main techniques to manage rhegmatogenous retinal detachment (RD): scleral buckling (SB), primary vitrectomy, and pneumatic retinopexy. Not only reattaching the retina but also obtaining an early visual recovery is an important factor when determining which surgical technique to perform to treat primary RD. Although SB surgery was established more than a century ago, there have been many changes in surgical techniques, materials, and instrumentations, and there is still a place for improvement.

The classical approach for SB is cryotherapy, placement of a buckle, and drainage of subretinal fluid. Cryotherapy has been blamed to cause excessive breakdown of blood–retinal barrier, leading to postoperative proliferative vitreoretinopathy (PVR), cystoid macular edema (CME), and vitreous haze. Laser can be used instead of cryo to avoid these complications. Laser retinopexy has been found to give comparable results in many studies.[1],[2],[3],[4],[5],[6] However, in these studies, laser was done postoperatively which is met with fear of early detachment, patient discomfort, and need for additional procedure.[4],[5]

As per our knowledge, no study has been done previously on intraoperative laser retinopexy during SB. The aim of this study was to assess the feasibility and efficacy of intraoperative laser retinopexy in SB surgery.

 Materials and Methods



This was a retrospective and interventional study. The study was approved by Institutional Review Board of Lumbini Eye Institute. Written informed consent was obtained from all patients. All patients who had undergone SB with intraoperative laser retinopexy were evaluated. Preoperative evaluation included best-corrected visual acuity, intraocular pressure, slit-lamp, and indirect examination. Extent of RD, number of breaks, type of breaks, and macular status were noted.

All surgeries were performed under local anesthesia by the same surgeon after obtaining the informed consent. After sterile draping, a 360° conjunctival peritomy was done. Bridle sutures were passed under recti muscles. Breaks were marked on sclera and a buckle of adequate size was placed along with encirclage band except for RD with a dialysis where only encirclage with 42 band was done. Subretinal fluid drainage was done using needle drainage technique. Adequate pressure was applied around drainage site with scleral indenter to drain as much subretinal fluid as possible. Globe volume was achieved with injection of intravitreal saline. Indirect ophthalmoscopy was done to ensure if all breaks were flat on the buckle. Buckle sutures were then permanently tightened. 532 nm argon green laser with indirect delivery system was used for laser retinopexy. All breaks were lasered with at least three rows of burns. The initial power setting used was 200 ms duration and 200 MW power. The duration (up to a maximum of 300 ms) and power were increased as required to achieve Grade 2 or Grade 3 laser burns. Conjunctiva was closed followed by subconjunctival injection of gentamicin and dexamethasone.

Follow-up was done on day 1, 2 weeks, 1 month, 3 months, and 6 months. Patients with follow-up of <6 months were excluded from the study. The primary outcome measure was anatomically attached retina at the end of 6 months.

 Results



Among 25 patients included in the study, 18 were male and 7 were female. The mean age was 24.32 years, ranging from 16 to 41 years. All patients were phakic with early presentation. Extent of RD was two quadrants in five, three quadrants in six, subtotal in five, and total in nine with macula off in all cases. Nearly 19 cases had single break, whereas 6 had >1 breaks, 5 cases had retinal tear (horseshoe), 3 had retinal dialysis, and 17 had atrophic holes. The preoperative vision was perception of light (PL) in 7 cases and hand movement (HM) in 18.

Adequate intraoperative laser was achieved in 22 of 25 (88%). In 3 of 25 (12%) patients, laser seemed to be inadequate around the break, so additional laser was done postoperatively.

Retina was attached in all patients at 6-month follow-up. None of the patients required additional procedure. All patients achieved good visual improvement. [Table 1] shows postoperative vision at 1-, 3-, and 6-month follow-up. Postoperative complications such as CME, epiretinal membrane (ERM), and PVR changes were not observed in any patients during 6-month follow-up.{Table 1}

 Discussion



The primary aim of RD surgery is closure of retinal break. Secondary aims include achieving chorioretinal adhesion around the break and subretinal fluid drainage. Reattachment of retina can be achieved even without cryotherapy or laser with just SB.[7] However, achieving a good chorioretinal adhesion is important for long-term success. This can be achieved with cryotherapy, laser, or diathermy. Diathermy has become obsolete now. The most commonly used method is cryotherapy. Cryotherapy has the advantage that it can pass through subretinal fluid and achieve good chorioretinal adhesion. However, cryotherapy is known to cause extensive breakdown of blood–retinal barrier[8] and intravitreal dispersion of viable retinal pigment epithelium[9] which can lead to development of PVR.[10] This effect is increased with treatment to larger and multiple tears and is related to the number and intensity of cryotherapy applications.[11] It can also cause vitreous haze and CME, macular puckering, postoperative lid edema, conjunctival chemosis, and pain.[4],[8],[12],[13],[14],[15],[16] These complications can be reduced using laser retinopexy.[17],[18]

Bonnet et al. found that laser therapy, as compared to cryotherapy, resulted in a lower postoperative PVR rate in patients with horseshoe tears with rolled posterior edges.[17] Laser has the advantage of inducing less intraocular inflammation and lesser breakdown of blood–retinal barrier. This can lead to faster visual recovery. Veckeneer et al. measured visual acuity and aqueous flare after SB using cryotherapy and postoperative laser.[1] He concluded that postoperative flare, as a measure of blood–ocular barrier breakdown, was significantly higher and visual recovery slower in the cryotherapy group. In a recent study of vitrectomy versus SB, the authors speculated that cryotherapy, by enhancing postoperative PVR, may be the main cause of increased reoperation rate in the scleral buckling group.[19]

There is no established timing of when postoperative laser is suitable.[4],[5],[20],[21] The efficacy of laser retinopexy in SB has been well established.[1],[2],[3],[4],[6] Because after subretinal fluid drainage the break is flat on buckle, laser around the break is easy. There is a concern that intraoperative laser may be difficult due to the surrounding residual subretinal fluid after drainage.[1],[5] However, we found that the area around break was flat on buckle after subretinal fluid drainage to allow adequate laser which is the aim of SB surgery. In our study, adequate intraoperative laser retinopexy was achieved in most cases (88%). In 3 of 25 (12%) cases, laser effect around break seemed to be inadequate, so additional laser was done on the first postoperative day. Intraoperative laser has the advantage over postoperative laser as it avoids an additional procedure. Laser in recent postoperative period can be painful. van Meurs et al. mentioned that patient discomfort was the main disadvantage of postoperative laser, with some patients even requiring peribulbar anesthesia.[5] Postoperative laser can be difficult if intraocular gas is injected during surgery. Furthermore, indirect laser with indentation can be difficult and painful in the postoperative period.

Intraoperative laser is more practical. Furthermore, by achieving an adequate intraoperative laser, the anticipation of early redetachment and frequent follow-ups to assess the possibility of laser is avoided. Postoperative laser retinopexy requires additional procedure plus added cost.[4] Lira et al. mentioned that intraoperative laser can be ineffective and induce more inflammation, but we did not notice any increased inflammation.[4] There is no established timing of when postoperative laser is suitable. van Meurs et al.[5] preferred doing laser at 6 weeks, whereas Lira et al.[4] did as early as possible. Early laser has the disadvantage of patient discomfort and difficulty in laser due to corneal edema or intraocular gas. Late laser has a risk of early redetachment, both of which can be avoided by achieving intraoperative laser. Furthermore, postoperative laser is impractical if the patient does not return for follow-up or allow laser treatment as in small children or mentally disabled person.[5]

Some surgeons have used intraoperative transscleral laser during SB.[6],[11],[22] Transscleral laser, however, requires high power and can induce more intraocular inflammation. Complications include scleral burns, subretinal hemorrhage, and breakage of Bruch's membrane.[23],[24],[25] Furthermore, they are not easily available.

The drawback of this study is that it was a noncomparative study with less number of patients. Furthermore, we were selective of cases. Only young phakic patients with no PVR or Grade A PVR were operated. This may be the reason for a good success rate. Prospective and comparative study using larger number of cases with high-risk characteristics and longer follow-up is required to assess the efficacy of intraoperative laser retinopexy. This study, however, clearly establishes the feasibility of intraoperative laser retinopexy during SB.

 Conclusion



Retinopexy can be achieved successfully using intraoperative laser. It can avoid postoperative complications usually associated with cryotherapy such as PVR, CME, and ERM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Veckeneer M, Van Overdam K, Bouwens D, Feron E, Mertens D, Peperkamp E, et al. Randomized clinical trial of cryotherapy versus laser photocoagulation for retinopexy in conventional retinal detachment surgery. Am J Ophthalmol 2001;132:343-7.
2McHugh DA, Schwartz S, Dowler JG, Ulbig M, Blach RK, Hamilton PA, et al. Diode laser contact transscleral retinal photocoagulation: A clinical study. Br J Ophthalmol 1995;79:1083-7.
3Haller JA, Lim JI, Goldberg MF. Pilot trial of transscleral diode laser retinopexy in retinal detachment surgery. Arch Ophthalmol 1993;111:952-6.
4Lira RP, Takasaka I, Arieta CE, Nascimento MA, Caldato R, Panetta H, et al. Cryotherapy vs. laser photocoagulation in scleral buckle surgery: A randomized clinical trial. Arch Ophthalmol 2010;128:1519-22.
5van Meurs JC, Feron E, van Ruyven R, Mulder P, Veckeneer M. Postoperative laser coagulation as retinopexy in patients with rhegmatogenous retinal detachment treated with scleral buckling surgery: A prospective clinical study. Retina 2002;22:733-9.
6Kapran Z, Uyar OM, Bilgin BA, Kaya V, Cilsim S, Eltutar K, et al. Diode laser transscleral retinopexy in rhegmatogenous retinal detachment surgery. Eur J Ophthalmol 2001;11:356-60.
7Fetkenhour CL, Hauch TL. Scleral buckling without thermal adhesion. Am J Ophthalmol 1980;89:662-6.
8Jaccoma EH, Conway BP, Campochiaro PA. Cryotherapy causes extensive breakdown of the blood-retinal barrier. A comparison with argon laser photocoagulation. Arch Ophthalmol 1985;103:1728-30.
9Campochiaro PA, Kaden IH, Vidaurri-Leal J, Glaser BM. Cryotherapy enhances intravitreal dispersion of viable retinal pigment epithelial cells. Arch Ophthalmol 1985;103:434-6.
10Bonnet M, Fleury J, Guenoun S, Yaniali A, Dumas C, Hajjar C, et al. Cryopexy in primary rhegmatogenous retinal detachment: A risk factor for postoperative proliferative vitreoretinopathy? Graefes Arch Clin Exp Ophthalmol 1996;234:739-43.
11Steel DH, West J, Campbell WG. A randomized controlled study of the use of transscleral diode laser and cryotherapy in the management of rhegmatogenous retinal detachment. Retina 2000;20:346-57.
12Dunker S, Faulborn J, Haller EM, Reich ME. The effect of retinal cryoapplication on the vitreous. Retina 1997;17:338-43.
13Kimball RW, Morse PH, Benson WE. Cystoid macular edema after cryotherapy. Am J Ophthalmol 1978;86:572-3.
14Sabates NR, Sabates FN, Sabates R, Lee KY, Ziemianski MC. Macular changes after retinal detachment surgery. Am J Ophthalmol 1989;108:22-9.
15Lobes LA Jr., Grand MG. Incidence of cystoid macular edema following scleral buckling procedure. Arch Ophthalmol 1980;98:1230-2.
16Lobes LA Jr., Burton TC. The incidence of macular pucker after retinal detachment surgery. Am J Ophthalmol 1978;85:72-7.
17Bonnet M, Guenoun S. Surgical risk factors for severe postoperative proliferative vitreoretinopathy (PVR) in retinal detachment with grade B PVR. Graefes Arch Clin Exp Ophthalmol 1995;233:789-91.
18Arrindell EL, Wu JC, Wolf MD, Nanda S, Han DP, Wong EC, et al. High-resolution magnetic resonance imaging evaluation of blood-retinal barrier integrity following transscleral diode laser treatment. Arch Ophthalmol 1995;113:96-102.
19Sahanne S, Tuuminen R, Haukka J, Loukovaara S. A retrospective study comparing outcomes of primary rhegmatogenous retinal detachment repair by scleral buckling and pars plana vitrectomy in Finland. Clin Ophthalmol 2017;11:503-9.
20Zaubermann H, Garcia Rosell F. Treatment of retinal detachment without inducing chorioretinal lesions. Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol 1975;79:OP835-44.
21Chignell AH. Retinal detachment surgery without cryotherapy. Trans Ophthalmol Soc U K 1977;97:30-2.
22Haller JA, Blair N, de Juan E Jr., De Bustros S, Goldberg MF, Muldoon T, et al. Transscleral diode laser retinopexy in retinal detachment surgery: Results of a multicenter trial. Retina 1998;18:399-404.
23Rol P, Barth W, Schwager M, Zuber N, Fankhauser F, Fankhauser S, et al. Devices for the control of laser transmission across the sclera during transscleral photocoagulation. Ophthalmic Surg 1992;23:459-64.
24Han DP, Nash RW, Blair JR, O'Brien WJ, Medina RR. Comparison of scleral tensile strength after transscleral retinal cryopexy, diathermy, and diode laser photocoagulation. Arch Ophthalmol 1995;113:1195-9.
25Haller JA, Blair N, de Juan E Jr., de Bustros S, Goldberg MF, Muldoon T, et al. Multicenter trial of transscleral diode laser retinopexy in retinal detachment surgery. Trans Am Ophthalmol Soc 1997;95:221-30.