The surgical approach to rhegmatogenous retinal detachment is still debated. While proponents of combined pars plana vitrectomy (PPV) and scleral buckle (SB) contend that the SB provides additional support to the vitreous base, there are surgical complications associated with the addition of the SB, including choroidal hemorrhage or explant extrusion. Smaller reports have produced conflicting results in evaluating solo PPV versus the combination of PPV and SB, but no meta-analysis of existing studies has been done to assess the outcomes of these procedures.
Three databases were searched: Ovid MEDLINE, Embase, and Cochrane Library, spanning from years 2000 to 2021. Both randomized controlled trials (RCTs) and observational studies were included, while case reports, editorials, reviews, and non-English studies were excluded. The primary outcomes included final best-corrected visual acuity (BCVA) and secondary outcomes included single operation success rate (SOSR), final reattachment rate, and complications. Appropriate data were extracted from the studies, and the risk for bias was determined using Cochrane risk-of-bias tools.
Thirty-eight studies were ultimately included in the analysis, with 10,397 eyes that underwent PPV and 5,264 eyes that underwent PPV and SB. There was no significant difference in BCVA at 6 months or at final follow-up between the two groups. PPV with SB was associated with statistically significantly higher rates of SOSR when compared to solo PPV (88.2% vs. 86.3%, P=.03). Contrastingly, the final reattachment rates were not statistically different between the two groups (96.3% vs. 96.8%). The rate of complications was found to be higher in the combined PPV and SB group, with significantly higher incidence of epiretinal membrane (9.1% vs. 8.1%, P=.02) and macular edema (19.0% vs. 6.0%, P=.02); however, when only studies published after 2010 were considered, this finding lost significance. Notably, there was no difference between the solo PPV group and the combined PPV and SB group in terms of extraocular motility, strabismus, or diplopia.
A subgroup analysis of the phakic group showed no difference in the final BCVA between either group. The psuedophakic group had a significantly higher SOSR (88.6% vs. 85.3%, P=.002) but no significant difference in final reattachment rate between the two groups. A subgroup analysis of proliferative vitreoretinopathy (PVR) grade C or worse showed no significant difference in the final BCVA between the two groups as well, but the eyes with significant PVR did show significantly higher SOSR in combined procedures as compared to PPV alone (89.2% vs. 86.2%, P=.009).
Overall, the meta-analysis showed a significantly higher SOSR with PPV and SB than with PPV alone, with the absolute difference between the groups remaining small, and the number needed to treat being 50. Additionally, patients with significant PVR may benefit from a combined approach rather than solo PPV.
The limitations of this analysis include limitations in reporting from the studies analyzed, and incomplete data. Additionally, the number needed to treat is high and it is difficult to draw clinical relevance from this. Moreover, observational studies were utilized in this meta-analysis, which have a greater potential for selection and confounding bias. Additionally, the follow-up periods were different in each study, which may impact the final BCVA. Despite the limitations, the authors have aggregated a great deal of data to help answer the question of best surgical approach for rhegmatogenous retinal detachments
October 2022: VBS Literature Update
Eshtiaghi A, Dhoot AS, Mihalache A, et al. Pars plana vitrectomy with and without supplemental scleral buckle for the repair of rhegmatogenous retinal detachment. Ophthalmol Retina. 2022;6(10):871–885.
Abstract by Sruthi Arepalli, MD
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Sruthi Arepalli, MD
Assistant Professor
Emory University
Vitreoretinal Surgery and Uveitis
Atlanta, GA
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