Scleral buckling and vitrectomy in retinal detachment

What is the aim of this review?
To find out the effectiveness and safety of vitrectomy combined with scleral buckle versus vitrectomy alone for eyes with giant retinal tear.

Key messages
Currently no conclusive evidence is available from randomized controlled trials comparing the effectiveness and safety of using a scleral buckle in a combined procedure with vitrectomy for giant retinal tear against using vitrectomy alone.

What was studied in this review?
The retina is a thin inner layer that lines the back of the eye and helps to send visual stimuli to the brain. The retina partially lines the vitreous body, a jelly-like fluid inside the eye. A giant retinal tear occurs when the vitreous body detaches from the retina (known as a retinal detachment) and creates a hole (retinal tear) of a certain size. For people who suffer retinal detachment associated with giant retinal tear, vitrectomy is usually indicated right away to prevent permanent vision loss. Vitrectomy is a type of eye surgery in which a doctor removes the vitreous and replace it with another solution.

For people with retinal detachment who are subjected to vitrectomy, this procedure can be combined with scleral buckling. Scleral buckling is a procedure to repair a retinal detachment in which a doctor attaches a piece of silicone or a sponge onto the white of the eye (scleral). Using scleral buckling may assist attachment of the retina.

What are the main results of the review?
Cochrane researchers searched for all relevant studies to answer this question and found only two conference abstracts, neither of which was published in full. Cochrane researchers also reached out to the investigators of these two studies but did not receive additional information.

People affected by giant retinal tears and retinal surgeons treating them need evidence to show whether it is useful to combine scleral buckle with vitrectomy. They need more information about the surgical procedure associated with a higher rate of retinal reattachment and reduced surgical risk. Future studies need to obtain information on outcomes for people affected by this condition, such as eye and systemic medical history, eye and retinal tear findings, vision gained from surgery, and adverse events associated with surgery.

How up-to-date is this review?
Cochrane researchers searched for studies published up to 16 August 2018.

Authors' conclusions: 

We found no conclusive evidence from RCTs on which to base clinical recommendations for scleral buckle combined with pars plana vitrectomy for giant retinal tear. RCTs are clearly needed to address this evidence gap. Such trials should be randomized, and patients should be classified by giant retinal tear characteristics (extension (90º, 90º to 180º, > 180º), location (oral, anterior, posterior to equator)), proliferative vitreoretinopathy stage, and endotamponade. Analysis should include both short-term (three months and six months) and long-term (one year to two years) outcomes for primary retinal reattachment, mean change in best corrected visual acuity, study eyes that required second surgery for retinal reattachment, and adverse events such as elevation of intraocular pressure above 21 mmHg, choroidal detachment, cystoid macular edema, macular pucker, proliferative vitreoretinopathy, and progression of cataract in initially phakic eyes.

Read the full abstract...
Background: 

A giant retinal tear (GRT) is a full-thickness neurosensory retinal break extending for 90° or more in the presence of a posterior vitreous detachment.

Objectives: 

To evaluate the effectiveness and safety of pars plana vitrectomy combined with scleral buckle versus pars plana vitrectomy alone for eyes with giant retinal tear.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 8), which contains the Cochrane Eyes and Vision Trials Register; Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Literature on Health Sciences (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in our electronic search. We last searched the electronic databases on 16 August 2018.

Selection criteria: 

We included only randomized controlled trials (RCTs) comparing pars plana vitrectomy combined with scleral buckle versus pars plana vitrectomy alone for giant retinal tear regardless of age, gender, lens status (e.g. phakic or pseudophakic eyes) of the affected eye(s), or etiology of GRT among participants enrolled in these trials.

Data collection and analysis: 

Two review authors independently assessed titles and abstracts, then full-text articles, using Covidence. Any differences in classification between the two review authors were resolved through discussion. Two review authors independently abstracted data and assessed risk of bias of included trials.

Main results: 

We found two RCTs in abstract format (105 participants randomized). Neither RCT was published in full. Based on the data presented in the abstracts, scleral buckling might be beneficial (relative risk of re-attachement ranged from 3.0 to 4.4), but the findings are inconclusive due to a lack of peer reviewed publication and insufficient information for assessing risk of bias.

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