Prophylactic scleral buckle for prevention of retinal detachment following vitrectomy for macular hole

Aim—To review the rate of retinal detachment after macular hole surgery in patients who received vitrectomy and scleral buckle versus those who had vitrectomy alone. Methods—All patient charts and hospital records were examined for patients who underwent vitrectomy surgery for macular hole between September 1993 and June 1997. A total of 326 patients were identified and all were followed for a minimum of 6 months. Clinical records were examined for details of the surgical procedure, visual acuity, hole closure status, adjuvant therapies used, and postoperative retinal attachment status. Relative risks (the ratio of the incidence rate in the exposed to that in the unexposed) with 95% confidence intervals and ÷ tests were calculated to determine which variables were associated with retinal detachment. The primary outcome measure in this review was retinal attachment status. Results—Of 326 eyes which underwent surgery for macular hole during the study period, scleral buckles were utilised in 152 (46.6%) patients. Analysis revealed a detachment rate of 13.2% in patients who did not receive a scleral buckle compared with 5.9% detachment rate in those who did. Analysis of these results indicated a 2.42 times greater risk of developing a retinal detachment in patients without a scleral buckle. Complications related to the use of scleral buckles occurred in two of 152 cases (1.3%) Conclusions—A reduction in the rate of retinal detachment was noted in patients receiving prophylactic scleral buckles. Those finding suggest a possible beneficial eVect of this adjunctive procedure in preventing postoperative retinal detachments. The authors are currently preparing a multicentred, prospective, clinical trial to further study this hypothesis (Br J Ophthalmol 1999;83:944–948) Macular hole is an idiopathic condition that typically aVects individuals in their sixth to seventh decade of life. In 1988, Gass postulated the role of tangential vitreous traction in the development of idiopathic macular hole. Since that time, several clinical trials have substantiated the eYcacy of vitrectomy for the treatment of patients with idiopathic macular hole. 4 Currently, the success rate for patients undergoing vitrectomy for macular hole ranges from 70% to 90%. With these results, surgical intervention has become the standard of care for patients with this condition. In two of the earlier series, the complication rates following macular hole surgery were reported to be quite low. Wendel et al reported a 1% detachment rate in a retrospective review of 170 eyes undergoing macular hole surgery. Smiddy and co-workers reported a 2% detachment rate in 90 eyes undergoing macular hole surgery with transforming growth factor â (TGF-â) adjuvant therapy. These statistics are in keeping with the suggested retinal detachment rates following vitrectomy surgery for epiretinal membranes. In a more recent study Park et al reported a much higher complication rate. In that article the authors noted a 14% rate of retinal detachment. This detachment rate was corroborated by the results from a prospective multicentred trial, which reported an 11% incidence of retinal detachment. Prophylactic scleral buckles have been suggested to be of benefit in selected cases of complex vitrectomies Rosner et al and Ahmadieh et al 12 have reported a reduction in the rate of retinal detachment after vitrectomy for penetrating ocular trauma. In these cases the detachment rates in the non-buckled group are significantly higher than those seen for conventional elective vitrectomy surgery. The role of circumferential traction and subsequent proliferative changes occurring after penetrating trauma are suspected to contribute to a 60–80% detachment rate postoperatively. 14 The higher complication rate in this disease group (that is, penetrating trauma) facilitates a statistical advantage in adjunctive therapy. To the best of the authors’ knowledge, there have been no studies to date investigating the potential beneficial eVect of prophylactic scleral buckles in patients undergoing macular hole surgery. In our centre, historical preferences have developed that have encouraged the use of prophylactic scleral buckles in selected cases. One of our surgeons in particular performs this adjunctive procedure on all vitrectomies for macular hole surgery. The other surgeons have a variable proportion of their macular hole patients undergoing prophylactic scleral buckling. This surgeon bias in the decision to perform a scleral buckle or not has allowed us a stratification from which we have retrospectively reviewed our series. Br J Ophthalmol 1999;83:944–948 944 Division of Vitreo-Retinal Surgery, Department of Ophthalmology, University of British Columbia, Vancouver, Canada