Surgical interventions for rhegmatogenous retinal detachment

Research question
In this review we aimed to determine whether pneumatic retinopexy or scleral buckle is a better surgical treatment for rhegmatogenous retinal detachment (RRD).

Background
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: pneumatic retinopexy, scleral buckle, and vitrectomy. In pneumatic retinopexy, 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 scleral buckle, 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 tamponade may be used to facilitate healing.

Study characteristics
We found two randomized trials that had enrolled a total of 216 participants (218 eyes) from Ireland and the United States. Both studies evaluated whether pneumatic retinopexy or scleral buckle was a better treatment for RRD. The study in the US had 198 participants with 6 months to 2 years of follow-up. The study in Ireland had 20 participants with 5 to 27 months of follow-up. The evidence is current to 13 January 2015.

Key results
Results from both studies suggested that scleral buckle may perform better or as well as pneumatic retinopexy in terms of reattachment rates and reducing the risk of recurrence of detachment. Few ocular adverse events occurred during either procedure and differences in some adverse events occurring after the surgeries could not be determined. More eyes in the scleral buckle group experienced choroidal detachment (separation of the choroid, the layer between the retina and sclera, from the sclera) and myopic shift (change to nearsightedness that may be a sign of developing cataract) than eyes in the pneumatic retinopexy group.

Quality of the evidence
The quality of the evidence was assessed as low to moderate due to poor reporting of how the studies were done. Further, there was lack of information regarding important outcomes that may be useful when choosing which procedure to use in terms of vision, quality of life, and cost.

Authors' conclusions: 

The evidence suggests that pneumatic retinopexy may result in lower rates of reattachment and higher rates of recurrence than scleral buckle for eyes with RRD, but does not rule out no difference between procedures. The relative safety of the procedures is uncertain and the relative effects of these procedures in terms of other patient-important outcomes, such as visual acuity and quality of life, is unknown. Due to the limited information available between pneumatic retinopexy and scleral buckle procedures, future research addressing these evidence gaps are warranted.

Read the full abstract...
Background: 

Rhegmatogenous retinal detachment (RRD) is a full-thickness break in the sensory retina, caused by vitreous traction on the retina. While pneumatic retinopexy, scleral buckle, and vitrectomy are the accepted surgical interventions for eyes with RRD, their relative effectiveness has remained controversial. 

Objectives: 

The objectives of this review were to assess the effectiveness and safety of pneumatic retinopexy versus scleral buckle or pneumatic retinopexy versus a combination treatment of scleral buckle and vitrectomy for people with RRD. The secondary objectives were to summarize any data on economic measures and quality of life.

Search strategy: 

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to January 2015), EMBASE (January 1980 to January 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to January 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 13 January 2015.

Selection criteria: 

We included all randomized or quasi-randomized controlled trials comparing the effectiveness of pneumatic retinopexy versus scleral buckle (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 forth by The Cochrane Collaboration.

Main results: 

We included two randomized controlled trials (218 eyes of 216 participants) comparing the effectiveness of pneumatic retinopexy versus scleral buckle for eyes with RRD. We identified no studies investigating the comparison of pneumatic retinopexy versus a combination treatment of scleral buckle and vitrectomy. Of the two included studies, one was a small study with 20 participants enrolled in Ireland and followed for an average of 16 months. The second study was larger with 196 participants (198 eyes) enrolled in the United States and followed for at least 6 months. Cautious interpretation of the results is warranted, since we graded the evidence as low to moderate quality due to insufficient reporting of study methods and imprecision and inconsistency among study results.

Both studies showed fewer eyes achieving retinal reattachment in the pneumatic retinopexy group compared with the scleral buckle group by six-months follow-up (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.77 to 1.02, 218 eyes); however, we are uncertain as to whether the intervention has an important effect on reattachment because the results are imprecise. Eyes in the pneumatic retinopexy group also were more likely to have had a recurrence of retinal detachment by six-months follow-up (RR 1.80, 95% CI 1.00 to 3.24, 218 eyes); however, we are uncertain as to whether the intervention has an important effect on recurrence because the lower CI equals no difference. Neither study reported mean change in visual acuity, quality of life data, or economic measures. Differences between the pneumatic retinopexy group and scleral buckle group were uncertain due to small numbers of events with respect to operative ocular adverse events (RR 0.67, 95% CI 0.32 to 1.42, 218 eyes), development of cataract (RR 0.92, 95% CI 0.06 to 14.54, 198 eyes), glaucoma (RR 0.31, 95% CI 0.03 to 2.91, 198 eyes), macular pucker (RR 0.74, 95% CI 0.20 to 2.67, 198 eyes), and proliferative vitreoretinopathy (RR 0.94, 95% CI 0.30 to 2.96, 218 eyes). Fewer eyes in the pneumatic retinopexy group compared with the scleral buckle group experienced choroidal detachment (RR 0.17, 95% CI 0.05 to 0.57, 198 eyes) or myopic shift equal to or greater than 1 diopter spherical equivalent (RR 0.04, 95% CI 0.01 to 0.13, 198 eyes).

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