Survey: More retinal surgeons using primary vitrectomy, microincisional technology

Take-home message: Surveys examining retinal surgeon-practice patterns for retinal detachment show preferences differ regionally.

By Cheryl Guttman Krader; Reviewed by Maria H. Berrocal, MD

San Juan, Puerto Rico-Results of surveys conducted by the American Society of Retina Specialists (ASRS) show there are some international differences in surgeon preferences for retinal detachment repair techniques.

Globally, however, the data from those surveys and other sources indicate increased utilization of vitrectomy, growing popularity of microincisional (23- and 25-gauge) procedures, greater movement into ambulatory surgery centers, and a declining role of general anesthesia.

“The increase in primary vitrectomy is likely explained by the fact that surgeons see it as being easier and faster than scleral buckle surgery,” said Maria H. Berrocal, MD, assistant professor of ophthalmology, University of Puerto Rico School of Medicine, San Juan. “In addition, as vitrectomy is used more often, there is less exposure in training programs to learning the scleral buckle procedure.

“The expanded role of 23- and 25-gauge valved cannulas corresponds with appreciation for the benefit of microincisional surgery in allowing faster procedures, but also with the introduction of wide-angle viewing and better cutter technology,” Dr. Berrocal added.

Drilling down to the details

According to recent data, vitrectomy accounts for more than 70% of procedures for rhegmatogenous retinal detachment (RRD) in the United States, Dr. Berrocal noted. Compared with 1997, utilization of vitrectomy is up 80%, while that of scleral buckle surgery decreased by 70%.

Vitrectomy is also preferred by surgeons outside the United States. However, when it comes to other techniques, U.S. surgeons chose pneumatic retinopexy more often than their colleagues in other countries.

Data from the 2014 ASRS Global Trends Survey show some differences in surgeon preferences depending on the specific clinical scenario.

For pseudophakic retinal detachment without PVR, primary vitrectomy was the preferred procedure for about three-fourths of surgeons around the world, with the exception of those in Central and South America.

For phakic eyes, U.S. surgeons would be twice as likely to perform vitrectomy compared with scleral buckle surgery (48% versus 23%). Elsewhere around the world, scleral buckle was the leading choice, although the size of the gap between it and vitrectomy varied in the different regions.

U.S. surgeons also differed from their international colleagues in their likelihood to perform combined cataract and vitrectomy surgery (41% versus 77%).

Data from U.S. surveys conducted in 2000 and 2012 showed that surgeons grew more likely to perform vitrectomy for eyes with floaters. In 2012, 72% of U.S. surgeons as well as 65% of surgeons internationally said they had performed that procedure.

Regarding treatment for diabetic tractional detachment, the majority of surgeons around the world indicated they would perform urgent panretinal photocoagulation. However, that procedure was more commonly chosen by U.S. surgeons than their international colleagues (76% versus 64%), whereas the international surgeons were more likely than U.S. surgeons to perform vitrectomy alone or closely following anti-vascular endothelial growth factor (VEGF) injection.

Anti-VEGF injection alone would be used by a minority of surgeons, but was considered the initial choice more often by those in the United States than elsewhere.

While data for the years 2006, 2011, and 2014 showed a global trend to smaller gauge vitrectomy surgery, in 2014, 25-gauge instrumentation predominated over 23-gauge among U.S. surgeons (52% versus 44%), whereas 23-gauge was being used more often elsewhere around the world.

U.S. surgeons also were more likely than their international colleagues to use valved trocars during surgery (69% versus 18% to 40%).

In addition, survey data revealed regional differences in the preferred dye for staining the internal limiting membrane. Indocyanine green was the leading choice in the United States (70%) and brilliant blue elsewhere (58% to 80%).

“That difference probably is explained by availability,” Dr. Berrocal said.

Perfluorocarbon liquids in vitrectomy for routine primary RRD without proliferative vitreoretinopathy were being used overwhelmingly more by surgeons outside the United States compared with the Americans, whereas chandelier and lighted lasers were being used mostly in the United States.

Maria H. Berrocal, MD

E: mariahberrocal@hotmail.com

This article was adapted from a presentation by Dr. Berrocal at the 2014 meeting of the American Academy of Ophthalmology. Dr. Berrocal is a consultant to and receives lecture fees from Alcon Laboratories and is a consultant to Alimera and Hemera.