Menu

  1. Home
  2. /
  3. Vitreo-Retinal Diseases–IV
  4. /
  5. FP1336 : Giant Retinal...

Share this post

Dr. Aman Khanna, K15766, Dr. Ashish Mitra, Dr. Alok Sen

Purpose -: To report the outcomes of Scleral buckle in patients with Retinal detachment due to Giant retinal dialysis

Methods -: It is a Retrospective study of patients who underwent Scleral Buckle + Cryo  for RD with Giant Retinal Dialysis ( 3 clock hours or more) from 2013 jan – 2018 march. The functional as well as the anatomical outcomes at 3 months were noted with records of buckle induced refraction changes and IOP

Results -: The study included 14 eyes of 14 patients, presenting to the OPD with RD associated with Giant retinal dialysis (3 clock hrs or more). The mean age was 26.8 years. There were 11 males and 3 females. Out of 14 cases 12 had a Macula OFF RD, with a mean presenting VA of 1/60 and mean follow up of 9.8 months. PVR changes noted were 10, 3 and 1 cases having Grade A, B and C PVR respectively. At the end of 3 month follow up, 11 had an attached retina whereas, 3 had a detached Retina and were advised VR sx.

Conclusion-: This study Substantiates that majority of RD’s associated with Gaint Dialysis can be effectively managed by SB + Cryo, thus avoiding the need for VR Sx

Introduction -:

Retinal dialysis, the disinsertion of the retina from the vitreous base, is an uncommon cause of retinal detachment, accounting for 8% to 17% of rhegmatogenous retinal detachments (1,2). Most commonly retinal dialysis is seen in younger age group with trauma being the commonest cause, however several studies have demonstrated hereditary factors also.(3,4,5,6)

Giant retinal dialysis, which is retinal disinsertion from the ora serrata with 90 degrees or more of circumferential extent (7), It becomes extremely important to differentiate it from giant retinal tears, as the surgical management of the two eitologies differ.  A retinal dialysis occurs within the vitreous base, whereas a retinal tear occurs posterior to vitreous base insertion.

In dialysis vitreous bridges the dialysis gap and is attached to the posterior margin of the dialysis and posterior vitreous detachment is absent thus preventing it from inversion. Conversely in giant tear vitreous remains strongly attached to the anterior margin of the tear and the posterior flap, without any vitreous adhesion is free to move and inverts towards disc due to gravity.(7)

There is abundance of literature supporting scleral buckle for management of retinal dialysis (8,9,10). whereas for giant retinal tears Vitrectomy is the choice of surgery, but for giant retinal dialysis which surgery to perform is a major question, as there is scarcity of literature on management of giant dialysis.

The purpose of this study was to report the outcomes of scleral buckle for retinal detachment associated with giant retinal dialysis.

Materials and Methods -:

This was a retrospective study conducted in the Retina Dept. of Sadguru Netra Chikitsalaya. Data of the patients undergoing Scleral Buckle plus Cryo from 2013 Jan to 2018 March was reviewed retrospectively.

Giant retinal Dialysis was defined as Retinal Dialysis of 3 clock hours or more.

Patients diagnosed with Rhegmatogenous retinal detachment associated with giant retinal dialysis treated with scleral buckle plus cryo and completing a minimum follow up of 3 months were included.

Patients having Dialysis less than 3 clock hours, h/o penetrating injury and a follow up less than 3 months were excluded.

Records of 14 eyes, which met the inclusion criteria were analysed for Age/Sex, presenting and postoperative VA, Duration of symptoms, association with trauma, Clock hour of Dialysis, Location of Dialysis, PVR status, type of Buckle, IOP status post buckle Surgery, refraction status post surgery, fellow eye periphery status.

Outcome measure was noted as Anatomical success defined as attached retina at final follow up, where as Functional Success was defined as VA equal or better than 6/18 (log mar 0.48)

Procedure -:

All patients underwent scleral buckle 276 tire along with 240 encircling band, crotherapy was performed along the margins of the dialysis, drainage was performed using a 26 G needle, post surgery all patients received topical steroids and anitibiotics for 7 days along with a course of oral steroids for 7 days.

Results -:

 Data analysis of 538 patients treated with SB plus Cryo  was performed, out of which 73 cases had a retinal dialysis, of these 73 eyes 14 eyes had a RD associated with GRD.

Base line characteristics of patients are mentioned in Table 1. The mean age noted was 26.28 years with a mean follow up of 9.8 months, we noted the mean presentation in days which was 105.92 and the mean presenting VA was 1.63 in log mar. At presentation 12 cases had a macula off status whereas 2 had a macula on with 12 cases having a total or subtotal RD at presentation.

The location of dialysis was ITQ in 6 cases, SNQ 3 cases, STQ 2 cases, 1 case each had superior, nasal and inferior dialysis. The grade of PVR was A in 10 cases, 3 had grade B PVR and 1 had Grade C PVR changes. 13 cases had a phakic status at presentation whereas 1 had a PCIOL implanted in sulcus.

We noted the incidence of retinal dialysis to be 13.4 % with incidence of GRD 2.3%. The association of GRD with trauma was noted in 12 of the 14 eyes, in 1 case the cause could not be elicited and in 1 eye GRD was noted post cataract surgery with a PCR.

Final anatomical success was achieved in 11 of the 14 eyes, of the 14 eyes 7 (50%) achieved a VA of better or equal to 6/18 (log mar 0.48), 4 eyes achieved VA of 6/24 to 6/60 (logmar 0.5- 1.0) and 3 eyes had a VA worse than 6/60 (log mar 1.0). Table 2 and 3 shows post operative anatomical and functional outcomes.

At final follow up 3 eyes had a detached retina and were advised vitrectomy. The 3 eyes which had a failed anatomical outcome 1 had grade C PVR at presentation 1 had grade A and 1 had B PVR. The macula status was off in 2 of these 3 eyes whereas 1 eye having a failed outcome had a macula on status at presentation.

Increase in VA from presentation was noted in 11 eyes, in 2 eyes it remained stable whereas in 1 eye with a macula on status at presentation it deteriorated at the final follow up.

We achieved anatomical success in 11 of 14 eyes (79%) and a functional success in 7 eyes (50%).

We did not note any intraoperative complication in any of the case, in early postoperative period raise in IOP was noted in 5 cases which was well controlled by Anti glaucoma medication in all cases within 3 months post operatively. None of the eyes required a surgical procedure. Phacoemulsification was performed in 1 eye at 6 month period post buckle, which had developed PSC changes post trauma.

Discussion-:

The incidence of RD associated with retinal dialysis in literature is noted to be 8 – 17 % (1,2), in present study we observed 13.4% incidence correlating well with the literature.

We did not found any study in literature demonstrating the incidence of GRD, in our study we found it to be 2.3%.

In today’s scenario the art of buckling seems to be dying with the introduction of modern day vitrectomy advances, as majority of surgeons opting for vitrectomy over buckle. Buckle surgery offers advantage of preserving the natural crystalline lens and also nullifying gas or silicon oil related complications.

There is a clear consensus in literature regarding the efficacy of SB with cryo for managing RD associated with retinal dialysis with a success rate of over 85% in various studies (8,9,10), despite this no study is available demonstrating the outcomes of buckle surgery in RD associated with GRD, there have been few authors having cases of GRD included in their study but literature lacks studies exclusively for GRD.

In present study we included cases exclusively having a GRD associated RD. Out of 14 cases of GRD 12 cases had a h/o trauma, whereas, cause of GRD could not be determined in 1 case and in 1 eye it was following a complicated cataract surgery with PCR.

Trauma is identified as a major causative factor for retinal dialysis (11,12) and it goes the same in our study for GRD, the most common mode of trauma in our series was found to be with Cricket ball. We had excluded cases of open globe injuries from our study owing to the fact of presence of co existing pathologies which could bias the outcomes.

Observing the patient profile it tends to show a male preponderance with occurrence in a relatively younger age group (mean age -26.3 years) which is similar published literature (13,14). This could be attributed to the fact that younger males tend to involve in more outdoor playing activities.

Literature review reflects that occurrence of PVR in cases of retinal dialysis is very slow as compared to rhegmatogenous RD’s, associated with breaks or HST’s (15). Keneddy Et al (15) postulated low incidence of PVR associated with retinal dialysis is primarily due to a vitreous barrier to the liberation of RPE cells from the subretinal space. RPE cells are known to proliferate and form preretinal membranes along with glial and inflammatory cells (16,17,18). Retinal detachment secondary to horseshoe retinal tears is always associated with posterior vitreous detachment (19). In such cases, the tear lies posterior to the vitreous base and a direct pathway exists from the subretinal space to the liquefied vitreous behind the anteriorly collapsed posterior hyaloid face, whereas the vitreous base in retinal dialysis-related detachments remains adherent to the posterior margin of the detached retina. The condensed collagen fibrils of the cortical vitreous in the region of the vitreous base may provide a significant barrier to the migration of RPE cells into the vitreous cavity and onto the inner retinal surface, thus leaving the RPE cells loculated within the subretinal space (15)

We observed that despite the mean presenting duration of 105 days aprox 3.5 months only 4 cases (28.3%) had grade B or worse PVR changes.

In consensus with previous studies with respect to retinal dialysis (8,10,15), we noted for GRD that the most commonly involved quadrant remains the ITQ (6 cases) followed by SNQ (3 cases) and STQ (2 cases), the hypothesis for this could be structure of the bony orbit and the presence of the nose leaves the inferotemporal quadrant of the globe most vulnerable to trauma,  Microcystoid degeneration of this portion of the retina may also be a predisposing factor (15).

We achieved a anatomical success in 11 cases (79%), which slightly lower than that of few studies showing 90% success in cases with retinal dialysis associated RD (8,10,20), it could be due to the fact that we exclusively chose cases of GRD.

We defined functional success as VA Better or equal to 6/18 (log mar 0.48) and 7 cases (50%) achieved this outcome the other 4 cases also had a significant increase in VA but was not able to achieve this VA was probably due to foveal thinning and ISOS loss. The functional outcome also correlated well with past literature for retinal dialysis associated RD’s. (8,20)

It is really important to differentiate it from giant retinal tears because the choice of Surgery for GRT is vitrectomy probably because in giant tear vitreous remains strongly attached to the anterior margin of the tear and the posterior flap, without any vitreous adhesion is free to move and inverts towards disc due to gravity (7), thereby making it difficult to settle it by scleral Buckle.

A retrospective design and a short follow up were the limitations of this study, but the strength of this study is that we chose cases of GRD exclusively which none of the previous studies have done.

To conclude, this study Substantiates that majority of RD’s associated with Gaint Dialysis can be effectively managed by SB + Cryo, thus avoiding the need for VR Sx

References –:

  1. Leffertstra LJ. Desinsertions at the ora serrate. Ophthalmologica. 1950; 119(1):1–16. [PubMed: 15404546]
  2. Hagler WS. Retinal dialysis as the cause of a special type of retinal detachment. South Med J. 1965; 58(12):1475–1482. [PubMed: 5861498]
  3. Kennedy CJ, Parker CE, McAllister IL. Retinal detachment caused by retinal dialysis. Aust N Z J Ophthalmol. 1997; 25(1):25–30. [PubMed: 9107392]
  4. Kinyoun JL, Knobloch WH. Idiopathic retinal dialysis. Retina. 1984; 4(1):9–14. [PubMed: 6729268]
  5. Hollander DA, Irvine AR, Poothullil AM, Bhisitkul RB. Distinguishing features of nontraumatic and traumatic retinal dialyses. Retina. 2004; 24(5):669–675. [PubMed: 15492620]
  6. Smiddy WE, Green WR. Retinal dialysis. Pathology and pathogenesis. Retina. 1982; 2(2):94–116. [PubMed: 7178683]
  7. Sharma YR, Reddy PRR, Singh D. Giant Retinal Tears. JK Science 2004;6(2):58-61
  8. Jonathan S. Chang, MD, Kyle Marra, Harry W. Flynn Jr., MD. Scleral Buckling in the Treatment of Retinal Detachment Due to Retinal Dialysis. Ophthalmic Surg Lasers Imaging Retina. 2016 April 01; 47(4): 336–340. doi: 10.3928/23258160-20160324-06
  9. Jan S1, Hussain Z, Khan U, Khan MT, Karim S. Retinal Detachment Due to Retinal Dialysis: Surgical Outcome After Scleral Buckling Asia Pac J Ophthalmol (Phila). 2015 Sep-Oct;4(5):259-62.
  10. Kwong TQ, Shunmugam M, Williamson TH. Characteristics of rhegmatogenous retinal detachment secondary to retinal dialyses. Can J Ophthalmol. 2014; 49(2):196–199
  11. RossWH.Traumaticretinaldialyses. ArchOphthalmol. 1981;99:1371-4. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/7259608
  12. TasmanW.Peripheralretinalchangesfollowingblunttrauma Trans Am OphthalmolSoc. 1972;70:190-8
  13. VoteBJ,CasswellAG.Retinaldialysis:arewemissingdiagnostic opportunities? Eye (Lond). 2004;18:709-13.
  14. CameronME.Non-traumaticdialysisintheyoung. Br JOphthal- mol. 1960;44:541-6.
  15. Kennedy CJ, Parker CE, McAllister IL. Retinal detachment caused by retinal dialysis. Aust N Z J Ophthalmol. 1997;25:25Y30.
  16. Mandelcorn MS, Macherner R, Fineberg E, Hersch SB.Proliferation and metaplasia of intravitreal retinal pigment epithelial cell autotransplants. Am. J. Opbtbalmol. 1975; 80:227-37.
  17. Macherner R, Van Horn DL, Aaberg TM. Pigment epithelial proliferation in human retinal detachment with massive periretinal proliferation. Am. J. Opbtbalmol. 1978, 85: 181-91.
  18. Van Horn DL, Aaberg TM, Machemer R, Fenzl R. Glial cell proliferation in human retinal detachment with massive periretinal proliferation. Am. J. Opbtbalmol. 1977; 84:383-93
  19. Lewis H, Kreiger AE. Rhegrnatogenous retinal detachment. In: Duane TD (ed.). Clinical Opbtbalmology, Vol. 3. Philadelphia: JB Lippincott, 1993; Ch. 27, 1-12
  20. Jon S, Hussain Z, Khan U, Khan MT, Karim S. Retinal Detachment Due to Retinal Dialysis: Surgical Outcome After Scleral Buckling. Asia Pac J Ophthalmol (Phila)2015;4(5):259-262

Table 1

(Preoperative baseline features of all cases)

 

Case no. Age/Sex Duration of presentation Mode RD Status Macula status PVR status Clock hour Dialysis Location of Dialysis Presenting VA
1 33/M 20 days Ball Sub total RD OFF A 3 IT 1.7
2 19/M 15 days Rubber tube Sub total RD OFF B 3 IT 1.0
3 35/M 15 Days none Sub total RD OFF A 3 IT 2.7
4 24/F 365 Days Stone Inf. RD OFF B 4 INF 1.6
5 21/F 60 Days Wood stick Sub total RD OFF B 3 IT 1.0
6 19/M 60 Days Ball Total RD OFF A 3 SN 3.0
7 19/M 15 Days Wood stick Total RD OFF A 3 SN 2.7
8 19/M 60 days Rubber Tube Sub total RD OFF A 3 ST 1.7
9 17/M 30 days Rubber tube Sup. RD ON A 3 Sup 0.2
10 70/M 1 day Cat SX POD 1 Sub Total RD OFF A 3 IT 1.7
11 42/F 9 Days Fan wing Sup. RD ON A 3 SN 0.8
12 8/M 6 MONTHS Ball Total RD OFF A 3 ST 1.7
13 20/M 6 MONTHS Ball Total RD OFF C 3 Nasal 1.7
14 12/M 12 Months Ball Sub total RD OFF A 3 IT 1.3

 

Table 2

(Anatomical Success)

Anatomical Outcome No.
Retina Attached 11
Retina Detached 3

 

Table 3

(Visual Outcome)

Visual outcomes No.
6/6 – 6/18 (logmar 0 – 0.4) 7
6/24 – 6/60 (logmar 0.5 – 1.00) 4
Worse than 6/60 (worse than logmar 1.00) 3

 

Leave a Comment