rd surgry when no break found.pdf

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Management of Retinal Detachment WhenNo Break Is Found

Alberto Salicone, MD, William E. Smiddy, MD, Anna Venkatraman, MS, William Feuer, MS

Objective: To review the results of 2 different surgical approaches in the management of primary rhegmat-ogenous retinal detachments (RDs) with undetected retinal breaks.

Design: Retrospective, consecutive, interventional case series.Participants: Medical records of 44 patients with uncomplicated macula-involving primary rhegmatogenous-

appearing RDs, but without retinal breaks detected preoperatively or intraoperatively, were reviewed.Methods: All study patients were operated by the same surgeon between 1989 and 2004 using 2 ap-

proaches: 26 (59%) patients underwent a scleral buckling procedure (SBP) with or without subretinal fluiddrainage, whereas 18 (41%) patients underwent scleral buckling combined with pars plana vitrectomy (PPV),fluidgas exchange, and broad application of endolaser.

Main Outcome Measures: Single operation and final postoperative anatomic success, and 2-month post-operative and final best-corrected visual acuity (VA) (negative logarithm of the minimum angle of resolution[logMAR]).

Results: Mean preoperative VAs were 1.73 logMAR units (median, 1.60; range, 0.482.60) in the combinedsurgery group and 1.52 logMAR units (median, 1.30; range, 0.302.60) in the scleral buckling group. Neitherpreoperative (P 0.33), 2-month postoperative (P 0.53), best-corrected (P 0.98), nor final (P 0.46) mean

VA showed any statistically significant differences between the 2 treatment groups. A single operation reattach-ment rate of 72% (13/18 cases) was achieved in the combined surgery group, compared with 61.5% (16/26 cases)in the scleral buckling group (P 0.17, log rank test). Immediate anatomic success rates were 89% after combinedtreatment and 38.5% after scleral buckling alone (P 0.002). At the final visit, the retina was attached in 15 (83.3%)patients who received the combined treatment and in 22 (84.6%) patients who underwent scleral buckling (P 0.900).Intraoperative subretinal hemorrhage occurred in 1 (5.6%) patient from the combined surgery group and in 2 (7.7%)patients from the scleral buckling group. Retinal incarceration in the drainage sclerotomy occurred in 1 (3.8%) caseduring the SBP. Proliferative vitreoretinopathy sufficient to require reoperation developed in 1 (5.6%) eye of thecombined surgery group and in 3 (11.5%) eyes of the scleral buckling group.

Conclusions: Scleral buckling is as effective in the management of uncomplicated rhegmatogenous RDs

with undetected breaks as is surgery combining scleral buckling and PPV. Ophthalmology 2006;113:398 403 2006 by the American Academy of Ophthalmology.

The critical step in successful rhegmatogenous retinal de-tachment (RD) surgery is to seal the causative retinal break.Despite clear visualization of the fundus, retinal breaks arenot found in 2.2% to 4% of phakic RDs.1,2 In aphakic andpseudophakic RDs, the incidence of nonvisualized breaks ishigher, reported as 7% to 16% and 5% to 22.5%, respec-tively.16 Such cases have traditionally been managed usingcircumferential buckling and broad application cryopexy,with a reported primary success rate of 53% to 85%.2,710

The rationale of encirclement is to support unseen retinalbreaks that might exist in the periphery by decreasing pre-sumed vitreous tractionas scleral buckling without reti-

nopexy has been reported to effect retinal reattachment insome cases.11 The combination of scleral buckling and parsplana vitrectomy (PPV) in these cases offers the possibilityof searching for obscure breaks internally and allows broadretinopexy (laser) with what may be less induced proliferativevitreoretinopathy (PVR), but removes a potential tamponadeeffect by the vitreous. The results of combined surgery con-trast. Some studies report good results1214; others concludethat PPV does not allow better detection of the break that wasmissed preoperatively.8,15 Another report shows no statisticallysignificant difference between the 2 techniques.16

The purpose of this study was to review and compare theresults of these 2 different surgical approaches in the manage-ment of primary rhegmatogenous RDs with undetected retinalbreaks.

Materials and Methods

The study protocol was approved by the institutional review boardof the University of Miami School of Medicine. The charts of all

Originally received: May 6, 2005.Accepted: October 3, 2005. Manuscript no. 2005-395.

From the Department of Ophthalmology, Bascom Palmer Eye Institute,University of Miami School of Medicine, Miami, Florida.

No author has any financial or intellectual conflicts of interest in thematerial presented herein.

Correspondence to William E. Smiddy, MD, Bascom Palmer Eye Institute,P.O. Box 016880, Miami, FL 33101-6880.

398 2006 by the American Academy of Ophthalmology ISSN 0161-6420/06/$see front matterPublished by Elsevier Inc. doi:10.1016/j.ophtha.2005.10.002


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patients operated for rhegmatogenous RDs from 1989 through2003 by one of the authors (WES) were reviewed (692 patients).This medical record review yielded 44 patients with primaryrhegmatogenous macula-involving RDs in which a definite breakcould not be seen preoperatively or intraoperatively by indirectophthalmoscopy despite a clear media. All cases with a mention ofsubstantial preoperative media opacities such as vitreous hemor-rhage, dense cataract, PVR, recurrent RD, or choroidal detachmentwere excluded from the study. Patients without macular involve-

ment were excluded, as these 12 were more commonly treated withscleral buckling alone, which may have biased outcomes. Patientsmanaged with vitrectomy alone also were excluded, as this mo-dality was reserved exclusively for eyes that were judged to be toorisky for scleral buckling, such as eyes with glaucoma implantdevices, or eyes with thin sclera. The patients were analyzed in 2groups: scleral buckling procedure (SBP) and scleral buckle plusPPV (combined). The decision of which approach to apply wasarbitrary, but possibly was biased by the surgeons general ten-dency towards avoiding vitrectomy in primary cases. Excludingthe cases as outlined above minimized that possible bias. Cases inwhich a retinal break or a probable retinal break was foundintraoperatively were also excluded; data concerning this scenariowere not reliably tabulated, but they far outnumbered the studygroups. Thus, cases without breaks were defined narrowly in thisstudy. Data regarding when a decision for management with vit-rectomy in addition to scleral buckling was made were not uni-formly ascertainable, but usually it was an intraoperative decisionto perform vitrectomy.

All operations were performed by the same surgeon usingmonitored anesthesia care. A 360 SBP was done in all the eyes inboth groups. In the SBP group, cryopexy of all suspicious areas

was performed, and subretinal fluid (SRF) was commonly drainedthrough a sclerotomy, which was closed with a preplaced 6-0 blacksilk suture. Extensive confluent application of cryopexy generallywas avoided. The combined group, additionally, underwent a3-port PPV. In most cases, a retinotomy was performed with a finediathermy tip and used for internal SRF drainage during fluidairexchange. Confluent laser burns were placed along the margins ofthe retinotomy and along the posterior margin of the buckle at leastthroughout the meridians of the detachment, but usually for 360,

using an 810-nm diode laser.The following preoperative data typically were recorded in patient

charts and were tabulated: patient age, gender, lens status (phakic,pseudophakic, aphakic), refractive error (myopia [6 diopters (D)]or high myopia [6 D]), extent of RD, duration of macular detach-ment, and preoperative best-corrected visual acuity (BCVA).

Postoperative data collected included intraoperative and post-operative complications, immediate postoperative retinal status (onthe first postoperative day), reoperations, final retinal attachmentstatus, BCVA at 2 months postoperatively and at final follow-upexamination, and duration of follow-up. All best-corrected Snellenacuity measurements were transformed into the logarithm of theminimum angle of resolution (logMAR) equivalent (negative log-MAR) to create a linear scale of visual acuity (VA). Three categoriesof anatomic outcome were determined: retina flattened, retina notflattened, and retina partially flattened. Partially flattened was definedas when the macula was attached, but SRF persisted elsewhere.

Statistical Methods

The comparison between the SBP group and the combined groupfor categorical variables was performed using the chi-square test or

Table 1. Demographic and Baseline Characteristics

Combined Group (n 18) SBP Group (n 26) P Value

Operated eye [n (%)]Right 10 (55.6) 18 (69.2) 0.53*

Left 8 (44.4) 8 (30.8)Mean (SD) age (yrs) 60 (24.2) 68 (19.8) 0.23

Median (range) 63.5 (992) 75.5 (1391)Gender [n (%)]

Male 16 (88.9) 13 (50) 0.01*Female 2 (11.1) 13 (50)

Mean (SD) follow-up (mos) 8.3 (7.9) 15 (22) 0.17

Median (range) 5 (0.329) 3.4 (0.0376.1)Mean (SD) visual acuity (logMAR) 1.73 (0.73) 1.52 (0.68) 0.33

Median (range) 5/200 (20/60HM) 20/400 (20/40HM)Mean duration of macular detachment (days) (SD) 31 (32.2) 36 (80.6) 0.8

Lens status [n (%)]Phakic 3 (16.7) 9 (34.6) 0.23*Pseudophakic 11 (61.1) 15 (57.7)Aphakic 4 (22.2) 2 (7.7)

Refractive error [n (%)]Myopia 6 diopters 0 1 (3.8) 1.0*

Myopia 6 diopters 0 5 (19.2) 0.07*Detachment extent [n (%)]

1 quadrant 5 (27.8) 5 (19.2) 0.47*2 quadrants 8 (44.4) 12 (46.2)3 quadrants 0 3 (11.5)4 quadrants 5 (27.8) 6 (23.1)

Macula status, [n (%)]Off 18 (100) 26 (100) NA

HM hand movements; logMAR negative logarithm of minimum angle of resolution; NA not applicable; SBP scleral buckling procedure; SD standard deviation.*Chi-square test or Fisher exact test.Students t test.

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the Fisher exact test, and that for continuous variables was per-formed using Students t test. KaplanMeier survival analysis wasused to compute the rate of reoperation for recurrent RD in bothgroups, and the reoperation rate between the 2 groups was com-pared using the log rank test. A P value of0.05 was defined tobe of statistical significance. All statistical analyses were per-formed using SPSS (version 12, SPSS Inc., Chicago, IL).

Results

Demographic and baseline characteristics of the 2 groups of pa-tients are summarized in Table 1. A total of 44 eyes of 44 patients

were included in this study: 18 in the combined group and 26 in theSBP group. Mean follow-up periods were 8.3 months (median, 5months; range, 8 days29 months) for the combined group and14.9 months (median, 3.4 months; range, 1 day76 months) for theSBP group. The patients ranged in age from 9 to 92 years (mean,60) in the combined group and from 13 to 91 years (mean, 68) inthe SBP group. In the combined group, the mean preoperative VAwas 1.73 logMAR units (median, 5/200; range, 20/60hand move-ments [HM]), the mean duration of macular detachment was 31

days (standard deviation [SD], 32.2), 17% of the patients werephakic, 61% were pseudophakic, and 22.2% were aphakic. In theSBP group, the mean preoperative VA was 1.52 logMAR units(median, 20/400; range, 20/40HM), the mean duration of macu-lar detachment was 36 days (SD, 80.7), 34% of the patients werephakic, 58% were pseudophakic, and 8% were aphakic. Therewere only 3 phakic patients in the combined group, and 9 in theSBP group.

All selected 44 eyes were diagnosed with a macular-involvingRD by study design. On the first postoperative day, the retina wasattached completely in 16 of 18 (89%) patients and partiallyattached in the remaining 2 (11%) patients after combined surgery(Table 2). On the first postoperative day, the retina was totallyflattened in 10 of 26 (38.5%) patients; 6 (23%) patients showed a

partial reattachment; and in 10 (38.5%) eyes, there was still amacula-involving detachment in the SBP group. Thus, immediatepostoperative anatomic success was significantly better for thecombined group (P 0.002).

The single operation reattachment rate of 72% (13/18 cases) inthe combined group was statistically indistinguishable from the61.5% (16/26 cases) in the SBP group (P 0.17, log rank test). At6 months, rates of cumulative attachment not requiring reoperationfor recurrent RD were 65% in the combined group and 46.5% inthe SBP group. Further PPV for RD was necessary for 5 (27.7%)eyes in the combined group and 10 (38.5%) eyes in the SBP group.The results at 2 months postoperatively also were similar in eachgroup, but reflect many of these reoperations (Table 2). Thesurvival without reoperation, expressed as cumulative percentage

(KaplanMeier survival analysis) of patients, is shown in Figure 1.At the final visit, the retina was completely attached in 15 (83.3%)

0 30 60 90 120 150 180 2 10 240 270 300 330 360

Days since initial surgery

0.0

0.2

0.4

0.6

0.8

1.0

lufsseccusnoitro

porpevitalumuC

Combined group

SBP group

Survival Functions for the two groups

Figure 1. KaplanMeier survival curve for no further surgery for recurrent retinal detachment in each group. SBP scleral buckling procedure.

Table 2. Anatomical and Functional Outcomes

CombinedGroup

(n 18)SBP Group

(n 26)P

Value

Postoperative day 1 anatomicsuccess

16 (89%) 10 (39%) 0.002*

Reoperations 5 (28%) 10 (38.5%) 0.17

Anatomic success at 2

Months

15/17 (88%) 20/21 (95%) 0.52

Mean (SD) BCVA (logMAR)at 2 Months

1.29 (0.72) 1.14 (0.75) 0.53

Mean (SD) BCVA (logMAR)postoperatively

0.97 (0.54) 0.96 (0.78) 0.98

Final anatomic success 15 (83%) 22 (85%) 0.9*Mean (SD) BCVA (logMAR)

at final visit1.07 (0.72) 1.26 (0.84) 0.46

One operation success 13 (72%) 16 (61.5%) 0.17

BCVA best-corrected visual acuity; logMAR negative logarithm ofminimum angle of resolution; SBP scleral buckling procedure; SD standard deviation.Thirty-eight patients had follow-up information at 2 mos postoperatively.*Chi-square test or Fisher exact test.Log rank test using KaplanMeier survival analysis.Students t test comparing visual acuity in logMAR units.

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patients in the combined group and in 22 (84.6%) patients in theSBP group (P 0.900).

The groups undergoing drainage of SRF or gas injection did nothave statistically significant different anatomic outcomes com-pared with the subgroup counterparts (Table 3). The combinedgroup had a mean BCVA at 2 months of 1.29 logMAR units (SD,0.72), mean BCVA of 0.97 logMAR units (SD, 0.54), and meanfinal BCVA of 1.07 logMAR units (SD, 0.72) (Table 2). The SBP

group had a mean 2-month postoperative BCVA of 1.14 logMARunits (SD, 0.75), mean best BCVA of 0.96 logMAR units (SD,0.78), and mean final BCVA of 1.26 logMAR units (SD, 0.84).Preoperative (P 0.33), postoperative at 2 months (P 0.53),best (P 0.98), and final (P 0.46) mean BCVA did not showany statistically significant differences between the 2 groups.

Significant complications encountered during the study in-cluded 3 cases of intraoperative subretinal hemorrhage: 1 (5.6%) inthe combined group and 2 (7.7%) in the SBP group ( Table 4). One(3.8%) case of retinal incarceration in the drainage sclerotomyoccurred in the SBP group. Proliferative vitreoretinopathy devel-oped in 1 (5.6%) eye of the combined group and in 3 (11.5%) eyesof the SBP group. Other postoperative complications includedepiretinal membrane formation (sufficient to undergo further sur-gery) in 3 (17%) cases in the combined group and in 1 (3.8%) casein the SBP group, choroidal detachment in 1 (5.6%) combinedgroup patient and 2 (7.7%) SBP group patients, and scleral buckleexposure requiring subsequent removal 6 months after initial sur-gery in 1 (5.6%) combined group patient.

Discussion

The inability to detect retinal breaks in a rhegmatogenousRD has been reported to be associated with a prognosispoorer than that of cases in which the break was identified.2

Small breaks, poor mydriasis, cortical remnants, capsular

opacification, glare or pitting from the intraocular lens im-plant, corneal opacification, or vitreous opacities may makeidentification difficult, especially because anterior breaksmore commonly occur in pseudophakic and aphakic RDs.Such cases commonly are managed with vitrectomy tech-niques. However, despite a clear view, retinal breaks cannotbe identified in a small subset. Various strategies have been

described to locate unseen retinal breaks. The configurationof the RD is associated with more likely break locations, sothe region of the search may be narrowed down.17 Griffithet al described the use of exploratory cryotherapy to high-light and to identify a retinal break as it was enveloped bythe developing iceball.7 An internal approach offers someadvantages that might result in the detection of breaks.Scleral external indentation together with endoilluminationand magnification during PPV may help locate previouslyundetected breaks.18 Also during vitrectomy, searching withan aspirating instrument or using perfluorocarbon liquidsmay disclose a stream of fluid exiting the subretinal spacevia the hole (Schlieren effect).19 Despite these suggestions

for the identification of nonvisualized breaks, there continueto be cases in which breaks cannot be diagnosed.

Several strategies have been proposed to treat an RDwhen there are no recognized breaks. Griffith et al per-formed an SBP with an encircling buckle placed anterior tothe equator, 360 cryotherapy, and SRF drainage.7 Thesuccess rate of this procedure with one operation was 66%.Wong et al performed a PPV including membranectomy (asindicated), scleral buckling, cryotherapy, and an internal gastamponade to treat similar cases, with a 60% rate of retinalreattachment.8 Desai and Strassman reported 100% initialsuccess in pseudophakic RDs with undiagnosed breaks bycombining SBP with vitrectomy, fluidgas exchange, and

endolaser photocoagulation12

; in their study, no patient hadsignificant preoperative PVR. They explained that the com-bined technique offered the possibility of releasing vitreo-retinal traction as well as tamponading unseen breaks. In1999, Brazitikos et al reported a 100% primary attachmentrate combining primary vitrectomy with perfluoro-N-octaneuse (without scleral buckling) in the treatment of pseu-dophakic RDs without visible breaks.14

On the other hand, some authors have not found vitrec-tomy to be of additional value in terms of success rate. Wuet al reported a high success rate with the SBP alone (72%)and concluded that the combined procedure was unneces-

Table 3. Anatomic Success by Drainage of Subretinal Fluid or Gas Injection in the Scleral Buckling Group (n 26 Eyes)

Postoperative Day 1 Anatomic Success

P Value*

Final Anatomic Success

P Value*nRetina Flattened

(n 10)Partial

(n 6)

Retina NotFlattened(n 10) n

Retina Flattened(n 22)

Partial(n 2)

Retina NotFlattened(n 2)

SRF drained 19 8 (42%) 4 (21%) 7 (37%) 0.812 19 15 (79%) 2 (10.5%) 2 (10.5%) 0.42SRF not drained 7 2 (28.5%) 2 (28.5%) 3 (43%) 7 7 (100%) 0 0Gas injected 9 3 (33%) 1 (11%) 5 (56%) 0.37 9 8 (89%) 0 1 (11%) 0.52Gas not injected 17 7 (41.2%) 5 (29.4%) 5 (29.4%) 17 14 (82%) 2 (12%) 1 (6%)

SRF subretinal fluid.*Chi-square test.

Table 4. Complications

Combined Group(n 18)

SBP Group(n 26)

Subretinal hemorrhage 1 (5.6%) 2 (7.7%)Retinal incarceration 0 (0%) 1 (3.8%)PVR 1 (5.6%) 3 (11.5%)Choroidal detachment 1 (5.6%) 2 (7.7%)ERM 3 (17%) 1 (3.8%)

ERM epiretinal membrane; PVR proliferative vitreoretinopathy; SBPscleral buckling procedure.


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sary for otherwise routine RD.20 Tewari et al compared theanatomical and visual results of scleral buckling alone ver-sus the combined procedure in patients with RD due toundetected breaks, finding no statistically significant differ-ence in outcomes between the 2 groups, but the number ofintraoperative and postoperative complications was higherin the combined surgery group.16 Pars plana vitrectomywithout a scleral buckle for primary rhegmatogenous RDs

(with identified retinal breaks) has also been described.2125The 2 groups of patients considered for comparison in

the current study were similar, and comparable to otherstudies with respect to macular involvement (in bothgroups, only macula-off RDs were included), duration ofmacular detachment (P 0.79), and preoperative VA (P 0.33)all factors that consistently have been shown toinfluence anatomic and visual success rates.2628 The reat-tachment rate with one operation was not statistically betterwith a scleral buckle alone or the combined surgical strategy(P 0.17). The higher anatomic results on the first post-operative day in the combined group were equalized by the2-month and final follow-up visits. Visual acuities at 2

months and best and final BCVAs were also similar for bothstrategies. Thus, these findings are in agreement with Wonget al8 and Tewari et al16 in that no clear advantage in termsof anatomic or visual outcomes could be attributable tocombining PPV and scleral buckling, compared with con-ventional scleral buckling techniques alone, for eyes withRDs due to unseen breaks.

Complication rates were similar in both groups in thisstudy. Neither strategy offered an overwhelming advantageon the basis of success or complication rates; only theinevitability of cataract extraction (CE) in the combinedgroupit is widely recognized that vitrectomy acceleratesthe formation of nuclear sclerosisdiffered convincingly.29

Thus, the need for CE is anticipated in each of these caseswith in a few months, whereas those in the SBP groupwould not be expected to require cataract surgery muchsooner than if they had not needed RD surgery. The numberof phakic cases in the current study was too small to allowa meaningful comparison.

There are several barriers preventing a more definitiveassessment of the question explored by this study. Practicetrends have shifted, with what seems to be a more commonbias towards vitrectomy (alone or in combination withscleral buckling) among more recently trained vitreoretinalsurgeons. There is no clear evidence-based justification forthat shift. This study has related the divergence of results in

the literature. A prospective randomized trial at a limitednumber of centers would seem impractical due to the lowrate of case ascertainment. However, a larger group ofcenters may introduce heterogeneity in diagnosis and man-agement that may similarly confound an answer. Beyondthat, in this study there was a 10% difference in success ratethat was not statistically significant, due to the relativelysmall sample size of cases. However, a prospective random-ized study expecting to demonstrate such a difference withan 80% or 90% power would require 800 or 1000 patients.A 20% difference would require 200 or 300 patients. Thus,it seems unlikely that such a study would be performed,

given the finding that only about 5% of patients met thesestudy criteria.

Although in certain cases there may be a better rationalefor combined surgerysubstantial PVR; concomitant visu-ally significant vitreous hemorrhage; or other ocular abnor-malities, especially in a pseudophakic eyein many there isnot. In the absence of an advantage to one strategy versusthe other, or a larger, definitive study, the management of

the majority of eyes with RD due to undetected breaksshould remain at the discretion of the surgeon.

References

1. Ashrafzadeh MT, Schepens CL, Elzeneiny II, et al. Aphakicand phakic retinal detachment. I. Preoperative findings. ArchOphthalmol 1973;89:476 83.

2. Norton EW. Retinal detachment in aphakia. Am J Ophthalmol1964;58:11124.

3. Cousins S, Boniuk I, Okun E, et al. Pseudophakic retinaldetachments in the presence of various IOL types. Ophthal-mology 1986;93:1198208.

4. Vatne HO, Syrdalen P. Retinal detachment after intraocular lensimplantation. Acta Ophthalmol (Copenh) 1986;64:5446.

5. McHugh D, Wong D, Chignell A, et al. Pseudophakic retinaldetachment. Graefes Arch Clin Exp Ophthalmol 1991;229:5215.

6. Bradford JD, Wilkinson CP, Fransen SR. Pseudophakic retinaldetachments: the relationship between retinal tears and thetimes following cataract surgery at which they appear. Retina1989;9:1816.

7. Griffith RD, Ryan EA, Hilton GF. Primary retinal detach-ments without apparent breaks. Am J Ophthalmol 1976;81:4207.

8. Wong D, Billington BM, Chignell AH. Pars plana vitrectomyfor retinal detachment with unseen retinal holes. Graefes ArchClin Exp Ophthalmol 1987;225:26971.

9. Criswick VG, Brockhurst RJ. Retinal detachment. 360 degreescleral buckling as a primary procedure. Arch Ophthalmol1969;82:64150.

10. Grizzard WS, Hilton GF, Hammer ME, Taren D. A multivar-iate analysis of anatomic success of retinal detachmentstreated with scleral buckling. Graefes Arch Clin Exp Ophthal-mol 1994;232:17.

11. Custodis E. Treatment of retinal detachment by circumscribeddiathermal coagulation and by scleral depression in the area oftear caused by imbedding of a plastic implant [in German].Klin Monatsbl Augenheilkd 1956;129:47695.

12. Desai UR, Strassman IB. Combined pars plana vitrectomy andscleral buckling for pseudophakic and aphakic retinal detach-ments in which a break is not seen preoperatively. OphthalmicSurg Lasers 1997;29:718 22.

13. Devenyi RG, de Carvalho Nakamura H. Combined scleralbuckle and pars plana vitrectomy as a primary procedure forpseudophakic retinal detachments. Ophthalmic Surg Lasers1999;30:6158.

14. Brazitikos PD, DAmico DJ, Tsinopoulos IT, Stangos NT.Primary vitrectomy with perfluoro-N-octane use in the treat-ment of pseudophakic retinal detachment with undetectedretinal breaks. Retina 1999;19:1039.

15. Lincoff H, Kreissig I. Extraocular repeat surgery of retinaldetachment. A minimal approach. Ophthalmology 1996;103:158692.

16. Tewari HK, Kedar S, Kumar A, et al. Comparison of scleralbuckling with combined scleral buckling and pars plana vitrec-

Ophthalmology Volume 113, Number 3, March 2006

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tomy in the management of rhegmatogenous retinal detachmentwith unseen retinal breaks. Clin Experiment Ophthalmol 2003;31:4037.

17. Lincoff H, Giesser R. Finding the retinal hole. Arch Ophthal-mol 1971;85:5659.

18. Rosen PH, Wong HC, McLeod D. Indentation microsurgery:internal searching for retinal breaks. Eye 1989;3:27781.

19. Friberg TR, Tano Y, Machemer R. Streaks (Schlieren) as asign of rhegmatogenous detachment in vitreous surgery. Am JOphthalmol 1979;88:9434.

20. Wu WC, Chen MT, Hsu SY, Chang CW. Management ofpseudophakic retinal detachment with undetectable retinalbreaks. Ophthalmic Surg Lasers 2002;33:3148.

21. Heimann H, Hellmich M, Bornfeld N, et al. Scleral bucklingversus primary vitrectomy in rhegmatogenous retinal detach-ment (SPR Study): design issues and implications. SPR Studyreport no. 1. Graefes Arch Clin Exp Ophthalmol 2001;239:56774.

22. Escoffery RF, Olk RJ, Grand MG, Boniuk I. Vitrectomywithout scleral buckling for primary rhegmatogenous retinaldetachment. Am J Ophthalmol 1985;99:27581.

23. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrec-tomy without scleral buckle for pseudophakic retinal detach-ments. Ophthalmology 1999;106:18115, discussion 1816.

24. Oshima Y, Emi K, Motokura M, Yamanishi S. Survey ofsurgical indications and results of primary pars plana vitrec-tomy for rhegmatogenous retinal detachments. Jpn J Ophthal-mol 1999;43:1206.

25. Hakin KN, Lavin MJ, Leaver PK. Primary vitrectomy forrhegmatogenous retinal detachment. Graefes Arch Clin Exp

Ophthalmol 1993;231:344 6.26. Hassan TS, Sarrafizadeh R, Ruby AJ, et al. The effect of

duration of macular detachment on results after the scleralbuckle repair of primary, macula-off retinal detachments.Ophthalmology 2002;109:14652.

27. Ross WH, Kozy DW. Visual recovery in macula-off rheg-matogenous retinal detachments. Ophthalmology 1998;105:214953.

28. Girard P, Karpouzas I. Visual acuity after scleral bucklingsurgery. Ophthalmologica 1995;209:3238.

29. de Bustros S, Thompson JJ, Michels RG, et al. Nuclear scle-rosis after vitrectomy for idiopathic epiretinal membranes.Am J Ophthalmol 1988;105:1604.


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