Posterior Retinotomy vs Perfluorocarbon Liquid to Aid Drainage of Subretinal Fluid During Primary Rhegmatogenous Retinal Detachment Repair (PRO Study Report No. 10)

Abstract

Purpose:

This work compares posterior retinotomy vs perfluorocarbon liquid (PFCL) for subretinal fluid (SRF) drainage during pars plana vitrectomy for primary rhegmatogenous retinal detachment (RRD).

Methods:

In this large, multicenter, retrospective comparative study, 2620 patients underwent pars plana vitrectomy (with or without scleral buckle) for uncomplicated RRD. Patients for whom SRF was drained via the primary break without retinotomy or PFCL were excluded; those who required both retinotomy and PFCL were similarly excluded. Remaining patients were separated into “retinotomy” and “PFCL” cohorts. Subgroup analysis was conducted for macula-on and macula-off subgroups. Postoperative outcomes were analyzed and compared.

Results:

A total of 760 eyes (82.7%) had retinotomy and 159 eyes (17.3%) had PFCL for drainage of SRF, and baseline characteristics between the 2 groups were similar. Postoperative analysis showed similar outcomes between the retinotomy and PFCL cohorts, including final visual acuity (P = .19), redetachment rate (P = .30), anatomic success (P = .28), presence of postoperative epiretinal membrane (P = .75), and other macular pathologies (P > .99). Subgroup analysis yielded similar outcomes for macula-on and macula-off subgroups. Postoperative presence of retained PFCL was 2.4%, possibly a factor in the slightly higher number of subsequent surgical procedures (P = .03) in the PFCL cohort.

Conclusions:

Postoperative outcomes for retinotomy vs PFCL during RRD repair are comparable, aside from slightly greater number of subsequent surgical procedures needed in the PFCL cohort. Our analysis suggests both techniques are reasonable tools in the repair of macula-on or macula-off RRD.

Keywords

retinal detachment retinotomy/retinectomy perfluorochemicals subretinal fluid drainage

Introduction

Drainage retinotomy is a surgical technique that involves the creation of a small retinal hole to facilitate the removal of subretinal fluid (SRF), in conjunction with pars plana vitrectomy (PPV), for the treatment of rhegmatogenous retinal detachment (RRD).¹ First described by Machemer in 1981 as a technique for relaxing the retina in proliferative vitreoretinopathy (PVR) and trauma,² retinotomy has since expanded to include more indications for its use. Specifically, drainage retinotomy was used by Charles to reduce bleeding and retinal incarceration associated with the removal of SRF through the sclera, choroid, and retinal pigment epithelium.³ In addition, the use of drainage retinotomy aids the management of bullous RRD, because the complete drainage of fluid significantly decreases the likelihood of retinal fold formation.⁴ Although there are benefits with retinotomy, complications associated with its use include visual field scotomas and PVR at the endodrainage retinotomy sites.⁵

Another effective and widely used technique in draining SRF is the use of perfluorocarbon liquids (PFCLs), first introduced by Chang in 1987, as a tool to manipulate the retina during RRD surgery. PFCLs are optically clear, low-viscosity agents with high specific gravity that have tensile properties similar to silicone oil.⁶ These properties contribute to their versatility as tools for use in retinal surgery, such as flattening the retina in RRD, peeling membranes in PVR, protecting the macular area, and draining suprachoroidal hemorrhage, among others.⁷ A significant complication associated with the use of PFCL is subretinal retention of the PFCL,⁸ which can cause central scotoma and irreversible retinal damage.⁹ Furthermore, PFCL is high in cost and has the potential for a higher rate of subsequent surgical procedures,^10,11 making it less cost-effective.

Removing SRF through a preexisting retinal break during fluid-air exchange eliminates the need for the creation of a new retinal hole through retinotomy, reduces the costs associated with PFCL use,¹⁰ and decreases the number of complications associated with both techniques.¹² On the other hand, this has been shown to result in incomplete drainage,¹² which can lead to other complications such as persistent SRF and/or retinal fold.^4,12,13

To date, a large, multicenter study analyzing retinotomy vs PFCL for treatment of RRD has not yet been reported. The purpose of this study is to present outcomes of both techniques for drainage of SRF during vitrectomy for RRD, and in particular, to determine whether either one is superior or higher in complications compared with the other.

Methods

A retrospective, comparative, multicenter study was conducted. A total of 2620 patients who underwent surgical repair for primary RRD from January 2015 to December 2015 were included in a database.¹⁴ Preoperative, intraoperative, and postoperative data were collected from several sites, including Associated Retinal Consultants, William Beaumont Hospital in Detroit, Michigan; Massachusetts Eye & Ear in Boston; Mid Atlantic Retina, Wills Eye Hospital in Philadelphia, Pennsylvania; The Retina Center in Minneapolis, Minnesota; The Retina Institute in St Louis, Missouri; and VitreoRetinal Surgery in Minneapolis, Minnesota. This study was approved at all locations by an institutional review board (IRB) and adheres to the tenets of the Declaration of Helsinki.

For the purposes of this study, patients who underwent vitrectomy with or without scleral buckle (SB) were included. Patients with giant retinal tear, PVR, or history of prior PPV were excluded from the overall cohort. In addition, patients who required both a retinotomy and PFCL intraoperatively (n = 37), or neither a retinotomy nor PFCL (n = 564), were excluded (see Conclusions). Patients were then separated into 2 treatment arms—retinotomy or PFCL, based on which SRF drainage technique was performed—for analysis and comparison.

Statistical analysis was carried out using XLMiner ToolPak (Frontline Systems Inc.) for Google Sheets. All categorical variables were analyzed using Pearson χ² test or Fisher exact test (if expected frequency values were less than 5). Continuous variables were evaluated using analysis of variance. Multivariate linear regression was used to assess associations between baseline characteristics and postoperative outcomes. Baseline characteristics with a P value of .10 or less were included in the regression models.

Results

Of 919 eyes that had PPV (with or without SB) for uncomplicated RRD and met the inclusion criteria, 760 (82.7%) had retinotomy and 159 (17.3%) had PFCL for drainage of SRF. Baseline demographics and characteristics are summarized in Table 1. Both retinotomy and PFCL treatment arms were matched by sex (P = .65), age (P = .23), preoperative visual acuity (VA) (P = .16), preoperative macula status (P = .064), extent of retinal detachment (RD) (P = .42), and presence of preoperative macular comorbidity (P = .85). SB use was more common in the retinotomy group (41.45%, P = .035). Linear regression analysis revealed retinotomy use (P = .02) and detached macula (P = .02) are predictors for SB use. In addition, attached macula status (P = .049) and SB use (P = .018) are associated with retinotomy.

Table 1.

Baseline Characteristics of Patients.

	Retinotomy	PFCL	P ^a
	(n = 760)	(n = 159)	P ^a
Patient sex
Female	260 (34.21%)	58 (36.48%)	.65^b
Age, y	62.88 ± 10.72	61.75 ± 12.01	.23^c
Eye
Right	403 (53.02%)	72 (45.28%)	.091^b
Preop VA, logMAR	1.13 ± 1.08	1.26 ± 1.09	.16^c
(Snellen)	(20/270)	(20/364)
Pseudophakic	425 (60.00%)	85 (53.46%)	.014^b
Vitreous hemorrhage	120 (15.79%)	29 (18.24%)	.52^b
Preop macula status Attached	246 (32.37%)	39 (24.53%)	.064^b
Detached	514 (67.63%)	120 (75.47%)
Extent of RD	5.60 ± 2.44	5.77 ± 2.38	.42^c
Scleral buckle use	315 (41.45%)	51 (32.08%)	.035^b
Tamponade agent Gas	739 (97.24%)	150 (94.34%)	.10^b
Silicone oil	21 (2.76%)	9 (5.66%)

Abbreviations: logMAR, logarithm of the minimum angle of resolution; PFCL, perfluorocarbon liquid; Preop, preoperative; RD, retinal detachment; VA, visual acuity.

^a Bold font indicates statistical significance (P < .05).

^b Pearson chi-squared test.

^cAnalysis of variance test.

Postoperative analysis showed similar outcomes between the retinotomy and PFCL treatment arms (Table 2). On average, the retinotomy group had a better final VA than the PFCL group (0.44 [Snellen equivalent, 20/55] vs 0.51 [Snellen, 20/65]); however, this was not statistically significant (P = .19) (Figure 1). Both groups had similar VA improvement, +0.69 (7 lines) for retinotomy and +0.75 (7.5 lines) for PFCL (P = .43). In addition, redetachment rate (P = .30), anatomic success (P = .28), presence of postoperative epiretinal membrane (ERM) (P = .75), macular hole (MH) (P > .99), and other macular pathologies (P > .99) were not statistically different between retinotomy and PFCL. The PFCL group, however, had retained PFCL in 2.4% (vs 0% in the retinotomy group), and a higher incidence of subsequent retinal surgical procedures (0.46 ± 0.88 vs 0.31 ± 0.73, P = .03). Follow-up time was 430.92 ± 162.05 days (PFCL cohort) vs 387.01 ± 163.29 days (retinotomy cohort; P = .002). There were no macular folds reported in either the retinotomy or PFCL treatment arms.

Table 2.

Postoperative Outcomes.

	Retinotomy	PFCL	P ^a
	(n = 760)	(n = 159)	P ^a
Final VA, logMAR	0.44 ± 0.60	0.51 ± 0.62	.19^c
(Snellen)	(20/55)	(20/65)
Average Δ logMAR VA	0.69 ± 1.09	0.75 ± 1.09	.43^c
Redetachment	111 (14.61%)	29 (18.24%)	.30^b
Postop ERM	15 (2%)	2 (1.26%)	.75^d
Postop macular hole	3 (0.40%)	0 (0%)	>.99^d
Postop macular fold	0 (0%)	0 (0%)	>.99^d
Retained PFCL	–	4 (2.5%)	–
Anatomic success	673 (88.55%)	136 (85.53%)	.28^b
Total subsequent retinal procedures	0.31 ± 0.73	0.46 ± 0.88	.03^c

Abbreviations: ERM, epiretinal membrane; logMAR, logarithm of the minimum angle of resolution; PFCL, perfluorocarbon liquid; Postop, postoperative; VA, visual acuity.

^a Bold font indicates statistical significance (P < .05).

^b Pearson chi-squared test.

^cAnalysis of variance test.

^dFisher exact test.

Figure 1.

Differences in preoperative and postoperative visual acuity (VA), measured in logarithm of the angle of resolution (logMAR) between the retinotomy and perfluorocarbon liquid (PFCL) cohorts. VA improved from pre–pars plana vitrectomy to post–pars plana vitrectomy for both drainage types (P < .001); however final VA did not differ between the 2 groups (P = .19).

Preoperative Macular Status Subgroup Analysis

Subgroup analysis further separated the 2 treatment arms based on preoperative macular status, whether the RD compromised the macula (“macula-off”) or not (“macula-on”). In the macula-off cohort (n = 634), a majority of patients had a retinotomy (81%) for drainage of SRF. Baseline characteristics were matched both in the macula-on and macula-off subgroups, including phakic status (P = .46 and .26, respectively), except for SB use (P = .003), in which a greater number was used in the retinotomy vs the PFCL treatment arm in the macula-off subgroup (44.55% vs 32.50%, respectively). Regression analysis revealed that use of retinotomy was associated with SB (P = .02) in this cohort.

Much like the analysis of the entire cohort, postoperative outcomes for the macula-off subgroup were similar between both the retinotomy and PFCL treatment arms. Notably, final VA (P = .92), redetachment rate (P = .55), and anatomic success rate (P = .73) was not statistically different. Postoperative presence of ERM (P = .23), MH (P > .99), and other macula pathologies (P = .93) were also similar between the 2 groups.

In the macula-on subgroup (n = 285), baseline characteristics were matched, including preoperative VA (P = .70), extent of RD (P = .68), and the presence of preoperative macular comorbidity (P = .39). On average, SB use was more prevalent in the retinotomy group (34.96%) than in the PFCL group (30.77%); however, this association was not statistically significant (P = .74). In addition, silicone oil insertion was similar between both groups (P > .99).

On analysis of postoperative outcomes for the macula-on subgroup, the retinotomy and PFCL treatment arms were not statistically different from each other. This included final VA (P = .73), redetachment rate (P = .44), and total subsequent retinal surgical procedures (P = .14). Occurrence of postoperative ERM (P = .31), MH (P > .99), and other macular pathologies (P > .99) were also similar (Table 3).

Table 3.

Postoperative Outcomes of Macula-On and Macula-Off Subgroups.

	Macula-on subgroup			Macula-off subgroup
	Retinotomy	PFCL		Retinotomy	PFCL
	(n = 246)	(n = 39)	P	(n = 514)	(n = 120)	P
Final VA, logMAR (Snellen)	0.31 ± 0.49	0.34 ± 0.51	.73^b	0.51 ± 0.63	0.57 ± 0.65	.92^b
	(20/41)	(20/44)		(20/65)	(20/74)
Redetachment	35 (14.22%)	8 (20.51%)	.44^a	76 (14.79%)	21 (17.50%)	.55^a
Postop ERM	4 (1.63%)	2 (5.13%)	.31^c	11 (2.14%)	0 (0%)	.23^c
Postop macular	2 (0.81%)	0 (0%)	.99^c	1 (0.19%)	0 (0%)	.99^c
hole
Anatomic success	219 (89.02%)	32 (82.05%)	.28^c	454 (88.33%)	104 (86.67%)	.73^a
Total subsequent retinal procedures	0.32 ± 0.72	0.51 ± 1.00	.14^b	0.37 ± 0.78	0.44 ± 0.85	.37^b

Abbreviations: ERM, epiretinal membrane; logMAR, logarithm of the minimum angle of resolution; PFCL, perfluorocarbon liquid; Postop, postoperative; VA, visual acuity.

^a Pearson chi-squared test.

^bAnalysis of variance test.

^cFisher exact test.

Conclusions

We present a retrospective, comparative multicenter study of 919 eyes that underwent internal drainage of SRF during PPV for treatment of primary RRD. This study aimed to compare postoperative outcomes for use of retinotomy vs PFCL for drainage of SRF. Our results revealed that retinotomy and PFCL use yield similar postoperative outcomes in the overall cohort as well as the macula-on and macula-off subgroups. Also, the success rates for retinotomy and PFCL use in RRD repair are similar to prior studies that examined these techniques.^10,15 Furthermore, postoperative macular complications such as ERM, MH, and macular fold are rare¹³ regardless of the method of draining SRF. The only postoperative differences identified were the presence of retained PFCL and increased number of subsequent retinal surgical procedures in the PFCL cohort, perhaps owing to retained PFCL.^16,17 The follow-up time was longer on average compared with the retinotomy cohort, and this is another possible factor as to why the number of subsequent procedures were higher in the PFCL cohort.

In the case of an existing silicone intraocular lens (IOL), PFCL is sometimes preferable to retinotomy because of reduced visibility of the retina through an IOL that becomes foggy during the air-fluid exchange.¹⁸ However, our study did not address silicone IOLs specifically and we did not find a preference for using PFCL in pseudophakic patients.

Patients who presented with worse VA or a larger extent of RD were more likely to have intraoperative retinotomy or PFCL as opposed to simple drainage of fluid through the existing retinal break (data not shown). This difference in baseline characteristics limited our ability to compare retinotomy and PFCL eyes with those that had neither in our present analysis. Our exclusion of the latter cohort was intentional because of dissimilar baseline characteristics, as patients in the “neither” cohort tended to have smaller detachments, less macula-off status, and better baseline VA (data not shown). Similarly, patients who underwent both retinotomy and PFCL generally presented with more complex RRDs (larger size, greater macula-off status, and worse baseline VA; data not shown), consistent with prior studies,^19,20 and were also excluded. Thus, a limitation of the present study is that it could not compare retinotomy and PFCL eyes with those that had neither, although we believe that drainage of SRF through the primary break (without retinotomy or PFCL) is an excellent option, especially for small peripheral detachments.

Other limitations of this study are that it is retrospective, and that the decision to use retinotomy vs PFCL to drain SRF was based on surgeon preference. Furthermore, we did not investigate the presence or absence of visual scotoma that may arise from either technique, in particular a posterior retinotomy.

In summary, this analysis provides support that when deciding between retinotomy vs PFCL for drainage of SRF, either technique is a reasonable tool in the repair of macula-on or macula-off primary RRD.

Footnotes

Ethical Approval

This study and patient involvement was approved by Salus IRB and the IRBs of the respective institutions. This study was conducted in accordance with the Declaration of Helsinki. The collection and evaluation of all protected patient health information was performed in a Health Insurance Portability and Accountability Act (HIPAA)—compliant manner.

Statement of Informed Consent

Informed consent is not needed for a retrospective review of medical records; the study was approved as noted in the ethical approval statement.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Phillips Eye Institute Foundation in Minneapolis, Minnesota, and the VitreoRetinal Surgery Foundation in Edina, Minnesota. The sponsors or funding organizations had no role in the design or conduct of this research.

ORCID iD

Loi V. Vo, MS

Yoshihiro Yonekawa, MD

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