Scleral Buckling Versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment

Scleral Buckling versus Primary Vitrectomy in
Rhegmatogenous Retinal Detachment

A Prospective Randomized Multicenter Clinical
Study
Heinrich Heimann, MD, Karl Ulrich Bartz-Schmidt, MD, Norbert Bornfeld, MD, Claudia Weiss, MD, Ralf-Dieter
Hilgers, PhD, Michael H. Foerster, MD
Presented by : dr. Rr. Widyastuti Pusparini
Supervised by : dr. Afrisal H. Kurniawan, Sp.M(K)
Introduction
• Rhegmatogenous retinal detachment (RD)  important indication for vitreoretinal
surgery  50% of all cases
• High anatomical success rates can be achieved by various techniques
• Flawed after surgery  40% cannot achieve reading ability, 10-40% need more than one
surgery (additional retinopexy or anterior segment surgery), 5% permanent anatomical
and functional failure
• Only few studies comparing effects of different surgical methods with outcome variable
• Optimal treatment of RRD  still on debate (mostly on results of retrospective of single
centre studies)
• SPR was designed to compare SB and PPV in rhegmatogeous RDs of medium complexity
in prospective multicenter analysis  to analyze the functional outcome
Introduction
Adjusment surgical
methods
Initial clinical
presentations
Anticipated level of
difficulty of the
situation
Introduction
50% patient with localized detachment (up to 4

Vast majority treated with SB
o’clock hours), with single or neighboring break
SPR STUDY
20% patient with complicated cases (PVR grade B Most commonly treated with
or C, giant break, macular hole) PPV
30% patient with medium severity (multiple breaks SB and PPV or

indifferent quadrants, bullous rhegmatogenour
RD’s combinationof both
Materials and Methods
randomized, controlled,
Parallel group design
prospective multicenter
(SB vs PPV)
clinical trial
Common inclusion criteria : primary

Based on Status of lens 
rhegmatogenous RDs, multiple
aphakic/pseudopakic patients and
breaks, duperior bullous
phakic patients  two parallel
detachment, central extension or
separate trials with one setting
breaks, marked vitreous traction
Exclusion criteria : RRDs that can be treated with radial episcleral sponge; breaks posterior
to the vessel arcades; PVR stage B or C; coexisting eye diseases that have an impact on VA;
previous intraocular surgeryl; myopia > -7D, systemic disease that may influence the
postoperative course or wound healing; pregnancy; and age <18 years.
SB  silicone sponge and/or encircling band
PPV  standard 3-port PPV with a 20% to 40%
sulfur hexafluoride–air mixture as endotamponade
and cryopexy or endolaser for retinopexy
necessity, timing, choice of

Fulfilling inclusion methods for revisional surgery
criteria   clinical findings
randomized for SB In eyes with silicone oil
or PPV tamponade  did not require
Interventions removal of silicon oil before
final follow-up examination
Establish
evidence-based
Functional recommendatio
outcome, ns for the
measured BCVA, treatment
anatomical Objectives:
outcomes,
To compare SB vs PPV
occurrence of
PVR in RRDs of medium
complexity
• the change in BCVA from the initial examination

Primary to the 12-month visit using letter-by-letter scoring
on Early Treatment Diabetic Retinopathy Study
(ETDRS) charts
End Point
• Proliferative vitreoretinopathy rate.
Secondary • Primary anatomical success
• Final anatomical success
end point • Number of retina-affecting procedures

• Development of cataract in the phakic trial
RESULT
Discussions
Preopera
tive
findings
Experienc Surgical Patient

e and treatment character
ability of of RD’s istics
surgeon
Available
tools for
surgery
SPR Study
Phakic
• Statiscally significant advantage SB over PPV
(main end point in BCVA, secondary end point
of cataract)
• cataract progression has also previously been
noted after SB  better outcomes even after
excluding significant cataracts
• no benefit was seen when combining PPV and
additional buckling
Pseudophakic/aphakic
• PPV showed a significantly greater proportion
of primary success
• In PPV group, a lower rate of retina-affecting
secondary procedures than the SB group
• PPV combined with additional scleral buckling
was particularly successful
SPR STUDY VS PREVIOUS STUDY
prospective Retrospectively
multicenter randomized trial single-center studies only
SB versus PPV in a comparable study investigated a rather small number of
popula- tion patients
Previous study  only 3 study observed all patients or a significant
interpret their data in favor of one of proportion of the study group for less
the two methods than a year
reflect the situation of RD surgery in Small group of patients with
daily clinical practice preoperative PVR grade
first trial of RD surgery to use ETDRS
charts for measurement of BCVA
no significant differences can be seen in
Sharma et al  PPV achieve better
functional outcomes between PPV with
functional results in 6 month follow up
SB in almost all studies
All other trials comparing SB

and PPV, including 3
prospective studies, seem to
have achieved significantly
worse functional results
than those of all SPR Study
reaches the greatest
recommendation level reflect the situation of level of clinical
first prospective large A1b for efficacy proof rhegmatogenous RD evidence compared
scale multicentre RCT of a therapeutic surgery in daily clinical with previously
intervention practice published trials on this
su
TERIMAKASIH
• MOHON BIMBINGAN DAN SARAN

• Tewari et al recommend SB in pseudophakic patients with
unseen breaks
• Sharma et al favor PPV in pseudophakic detachments
• Oshima et al found a small subgroup of patients with macula-off
detachments of long duration or preoperative hypotony in which
PPV led to a faster visual rehabilitation compared with SB
Previous Study SPR Study
• For a PPV, a review of 25 reports of • with 73% (phakic) and
series showed primary success rates of 78%(pseudophakic) in the SPR Study
85%(phakic) and 91% (pseudophakic) • In the SPR Study, postoperative PVR
• 3 reported prospective PPV series had rates were 17.7% (phakic)and 15.3%
primary success rates 62% - 84% (pseudophakic)
• For a PVR, a retrospective PPV series • PVR rate and the final success rate of
showed postoperative PVR between 97.4% and 94.6% for phakic and
0% and19% pseudophakic rhegmatogenous RDs
• In 3 prospective trials, the PVR rates compare favorably with the values
were 4%, 15% and 34% given in the literature
• Recent studies of SB  more difficult to compare  often
treated with PPV
• Recently reported larger series of SB achieved primary
anatomical success rates between 82% and 88%.
• Prospective series again show lower success rates for SB,
between 68% and 76% In the SPR Study, primary success rates
were 73% in the phakic subgroup and 61% in the
pseudophakic subgroup. The PVR rate in recent retrospective
series of SB varied between 4% and 11%. In the prospective
trials of SB, postoperative PVR grade B or C was seen in 20%,
25%, and 37%.
Ancillary Analyses
• The rate of cataract was greater in the
PPV group (58.0% [120/207]) than in the
Cataract surgery was recommended SB group (20.6% [43/209]), with a
during follow-up in the phakic trial significant difference of 37.4% (95% CI,
28.7%–46.1%)
application of additional buckling in the

PPV group correlated greatly with the lens The PVR rates do not differ in the
status of the patient  66.7% (88/132) pseudophakic patients (11.4% (10/88)
pseudophakic vs 50.7% (105/ 207) phakic) with an additional buckle vs 22.7% (10/44)
There is no difference (logistic regression without a buckle), showed PVR grade B or
model) to PVR development and the use C (difference, 11.4%; 95% CI, 2.7 to 25.4
of additional buckle alone (p= 0.9856)
redetachment rates do not differ
in the phakic patients, with 29.5%
(31/105) with an additional
buckle, compared with 20.6%
(21/102) without a buckle,
resulting in a rate difference of
8.9% (95% CI, -2.8% to 20.7%)

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Scleral Buckling versus Primary Vitrectomy in

Rhegmatogenous Retinal Detachment

50% patient with localized detachment (up to 4

30% patient with medium severity (multiple breaks SB and PPV or

Common inclusion criteria : primary

necessity, timing, choice of

• the change in BCVA from the initial examination

end point • Number of retina-affecting procedures

Experienc Surgical Patient

All other trials comparing SB

• MOHON BIMBINGAN DAN SARAN

application of additional buckling in the

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