Treating recurrent pediatric retinal detachment after initial repair

Take-Home

Recurrent retinal detachments in children can develop months to years after the initial corrective surgery, making careful monitoring of patients imperative to identifying late re-detachments.

Durham, NC-Recurrent retinal detachments in children can develop months to years after the initial corrective surgery, making careful monitoring of patients imperative to identifying late re-detachments.

Laura A. Vickers, MD, representing a research team that includes Joseph Martel, MD, and Prithvi Mruthyunjaya, MD, from Duke Eye Center in Durham, NC, shared the results of a study of pediatric patients with retinal detachments that evaluated the factors involved in retinal re-detachments following successful initial surgical interventions.

Challenges in pediatric cases

“Compared with adults, pediatric retinal detachments have different etiologies and typically, a later time to presentation,” explained Dr. Vickers, ophthalmology resident at Duke Eye Center. “The surgical success rates vary widely, but there are few data on the time to re-detachment, the clinical factors associated with re-detachment, and the benefit of multiple corrective surgeries.”

To address these issues, Dr. Vickers and colleagues studied pediatric retinal detachments in patients from 1997 to 2011. Of 314 identified patients, 144 patients (156 eyes) were included; seven surgeons performed all procedures. The investigators sought to determine the sustained re-attachment rate after the initial surgery, the time to re-detachment, and the complication rate after multiple surgeries.

The patient characteristics included median age at surgery of 11 years and the median best-corrected visual acuity (BCVA) of counting fingers; 75% were boys, and 49% of patients had undergone a previous intraocular surgery. More than two thirds of the detachments were rhegmatogenous and the remainder was tractional or combined traction rhegmatogenous retinal detachments. Posterior vitreoretinopathy (PVR) was present in 46% of patients at presentation. The initial surgery was combined scleral buckling and pars plana vitrectomy in 63% of eyes, scleral buckling alone in 12%, and vitrectomy alone in 25%.

“After the initial surgery, 53% of eyes had sustained retinal re-attachment with a final median BCVA of 20/200,” Dr. Vickers said. “Re-detachment occurred during follow-up in 45% of eyes, and in 2% the retina never re-attached, which was associated with a final BCVA of light perception. The median time to retinal re-detachment was 179 days.”

This highlights the challenges of retinal detachment repair in a pediatric population.

Re-attachment surgery rates

Thirty eyes required two or more surgeries to achieve a final re-attachment rate of 72%. Eyes with the macula re-attached at final follow up had a final mean vision of 20/525, and eyes with complete retinal re-attachment at last follow up had a mean vision of 20/200. The eyes in which the retina re-detached at any point during follow-up had a lower mean vision, and had a higher risk of having no light perception vision, developing phthisis, or needing enucleation, she said.

The investigators found that the factors associated with sustained attachment were macula on status at presentation, a rhegmatogenous-type retinal detachment, and scleral buckling performed during the initial surgery.

The latest re-detachments occurred in eyes with tractional or combined tractional and rhegmatogenous detachments, at more than 2,000 days after the initial surgery. Eyes with a rhegmatogenous retinal detachment tended to detach at a mean of 116 days after the initial surgery, Dr. Vickers noted.

Eyes in which the retinas re-detached early (less than 40 days after the initial surgery) were more likely to have been rhegmatogenous retinal detachments. Eyes in which the retina re-detached late (40 days to 1 year after the initial surgery) had more retinal breaks, were more likely to have undergone previous pars plana lensectomy, and had more PVR. These eyes were more likely to develop phthisis and no light perception vision, and overall had worse visual outcomes; eyes with very late re-detachment more than 1 year after the initial surgery were more likely to be combined detachments, to have had a previous PPV, and also had worse visual outcomes.

More than three surgeries less effective

Eyes that achieved retinal re-attachment through three or fewer surgeries tended to fare better. Eyes that required four to six surgeries for retinal re-attachment trended toward worse visual outcomes and more complications, Dr. Vickers explained.

“Interestingly, in eyes in which the macula was successfully re-attached, if more surgeries were required to achieve this, the trend was toward worse vision,” she said.

The investigators also found an increasing rate of complications after four or more surgeries were performed. At the same time, eyes with final macular re-attachment fared better in terms of serious complications than those that remained detached, regardless of how many surgeries were required, suggesting an anatomic benefit.

Summarizing the findings

In children, retinal re-detachment can occur months to years after the initial surgical intervention, so patients should be monitored closely, Dr. Vickers said.

“Up to three attempts at corrective surgery favors anatomic re-attachment, improved vision, and fewer severe complications,” she said. “After four surgical attempts, the benefits to vision diminish and more serious complications develop.

“However, those that are successfully repaired experience fewer serious complications,” Dr. Vickers concluded. “The factors associated with re-detachment include macular involvement and PVR. Using a scleral buckle seems to favor sustained attachment in the right clinical context. The development of adjuvant treatments to treat PVR in children is crucial, and scleral buckles should be used whenever appropriate.”

Laura A. Vickers, MD

E: laura.vickers@duke.edu

Dr. Vickers has no financial interest in the subject matter. This article was adapted from Dr. Vickers’ presentation during the 2012 meeting of the American Academy of Ophthalmology.

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