Retinal Detachment Surgery

The Dilemma Between Personal Experience and Clinical Trials

Peter Walter

Disclosures

Expert Rev Ophthalmol. 2012;7(5):441-447. 

In This Article

Expert Commentary

In a meta-analysis, Saw and coworkers compared trials on retina detachment surgery and found no clear evidence in favor for any technique. It seemed that too many aspects are important for the decision and too many aspects are modifiers of outcome.[76] Taking all the available information into consideration, surgeons have to consider several aspects when planning retinal detachment surgery. These aspects are illustrated in Figure 1.

Figure 1.

Diagram illustrating the factors influencing decision-making in vitreoretinal surgery for retinal detachments.
OR: Operating room; PVR: Proliferative vitreoreinopathy.

Decision-making in surgery is not only a matter of using the algorithms given in evidence-based approaches such as clinical trials or consensus recommendations but other factors also influence the decision. Whereas the patient's factors and medical science factors are more or less objective the personal view of the surgeon is very individual. A surgeon may decide because of his much greater experience in SB that in a given situation of for example, a pseudophakic retinal detachment he decides for SB rather than for vitrectomy even if the resources are available and even if prospective randomized clinical trials showed that vitrectomy gives better results. The surgeon's experience is greatly dependent on the training site, on the senior staff strategy in retinal detachment surgery at this training site, on the capability of teaching and mentoring and on own experiences during the learning curve. Of course it is also dependent on individual skills and on numbers of training procedures.

Weighing of each of factors given in Figure 1 significantly influences the choice of the surgeon. In general, vitrectomy is currently applied more and more also for simple detachments even in phakic eyes knowing that cataract formation will affect visual acuity negatively. Therefore some surgeons advocate to perform vitrectomy always in combination with cataract surgery for each patient with a phakic retinal detachment to prevent postoperative cataract.

Besides the individual affinity of a surgeon for a method, the following recommendations can be given for those who start vitreoretinal surgery:

  • Simple detachment (phakic eye, one break less than 1 o'clock size, shallow detachment, no PVR, no visible traction, and good visibility): SB or PR (if the resources for SB are not given);

  • Complex detachment (pseudophakic eye or bad visibility, PVR, large breaks, multiple breaks, irregular breaks, central breaks or other complicating factors): primary vitrectomy or primary vitrectomy plus SB.

The efficacy of an additional encircling element in primary vitrectomy is currently investigated in the VIPER trial, a large multicenter randomized clinical trial in pseudophakic retinal detachments. Results are expected in Summer 2013.

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