Abstract
Objective
To describe a novel classification system for primary rhegmatogenous retinal detachment
(RRD) based on level 1 evidence assessing the functional outcomes of repair techniques
with the goal of using a minimally invasive detachment surgery.
Methods
A systematic review and network meta-analysis of randomized, controlled trials comparing
pneumatic retinopexy (PnR), scleral buckle (SB), or pars plana vitrectomy (PPV) for
RRD was conducted. Primary outcomes were best-corrected visual acuity (BCVA), metamorphopsia,
and operative complications. A meta-analysis was performed with a random effects maximum
likelihood model, with outcomes of standardized mean difference (SMD) or risk ratio
(RR) and 95% confidence interval. Inclusion and exclusion criteria were assessed to
inform a classification system.
Results
Fourteen trials were included. RRDs were classified from categories 1–3 based on configuration
(simple to complex). There was no significant difference in final BCVA between PnR
and PPV (categories 1 and 2; SMD = –0.10, 95% CI –0.24 to 0.04), nor was a final BVCA
difference found between SB and PPV (SMD = 0.01, 95% CI –0.05 to 0.08), combined SB + PPV
and PPV (SMD = 0.02, 95% CI –0.08 to 0.12), or combined SB + PPV and SB (SMD = 0.01,
95% CI –0.11 to 0.12). SB had an elevated risk of choroidal detachment (RR = 5.17,
95% CI 1.68–15.97), hypotony (RR = 12.26, 95% CI 1.63–92.04), and strabismus or diplopia
(RR = 5.86, 95% CI 1.04–32.91) compared with PPV but a lower risk of iatrogenic breaks
(RR = 0.08, 95% CI 0.02–0.43). Vertical metamorphopsia scores were superior for PnR
over PPV at 12 months (Pneumatic Retinopexy versus Vitrectomy for the Management of
Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial, p = 0.026).
Conclusion
This novel classification system may be useful for future trials assessing morphologic
categories of RRD in a systematic manner. Minimally invasive detachment surgery may
allow for trials to focus on maximizing functional outcomes while minimizing morbidity.
Objectif
Décrire un nouveau système de classification du décollement de rétine rhegmatogène
(DRR) primaire fondé sur des données de niveau 1 qui évaluent les résultats fonctionnels
des différentes modalités de réparation dans l'optique de recourir à une chirurgie
micro-invasive.
Méthodes
On a procédé à une revue de synthèse systématique et à une méta-analyse en réseau
d’études comparatives randomisées qui examinaient la rétinopexie pneumatique (RP),
le cerclage scléral (CS) et la vitrectomie par la pars plana (VPP) dans le traitement
d'un DRR. Au nombre des paramètres principaux, citons la meilleure acuité visuelle
corrigée (MAVC), la métamorphopsie et les complications intraopératoires. On a eu
recours à un modèle d'effets aléatoires reposant sur la méthode du maximum de vraisemblance
pour réaliser la méta-analyse. Les résultats comprenaient la différence moyenne standardisée
(DMS) ou le risque relatif (RR) et l'intervalle de confiance (IC) à 95 %. Les critères
d'inclusion et d'exclusion ont été évalués pour bâtir le système de classification.
Résultats
Les DRR des 14 études retenues ont été classés de 1 à 3 en fonction de leur morphologie
(de simple à complexe). On ne note aucune différence significative quant à la MAVC
finale entre la RP et la VPP (catégories 1 et 2; DMS : –0,10; IC à 95 % : –0,24 à
0,04), ni entre le CS et la VPP (DMS : 0,01; IC à 95 % : –0,05 à 0,08), entre la combinaison
CS + VPP et la VPP seule (DMS : 0,02; IC à 95 % : –0,08 à 0,12) ou entre la combinaison
CS + VPP et le CS seul (DMS : 0,01; IC à 95 % : –0,11 à 0,12). Le CS s'accompagnait
d'un plus grand risque de décollement de la choroïde (RR : 5,17; IC à 95 % : 1,68
à 15,97), d'hypotonie (RR : 12,26; IC à 95 % : 1,63 à 92,04) et de strabisme ou de
diplopie (RR : 5,86; IC à 95 % : 1,04 à 32,91), comparativement à la VPP, mais il
présentait un risque moindre de déchirures iatrogènes (RR : 0,08; IC à 95 % : 0,02
à 0,43). Les scores de métamorphopsie verticale obtenus à 12 mois étaient plus élevés
après la RP qu'après la VPP, selon l’étude PIVOT (p = 0,026).
Conclusion
Ce nouveau système de classification sera utile lors des futures études qui examineront
de façon systématique les catégories morphologiques du DRR. Il est possible que les
interventions chirurgicales micro-invasives du DRR puissent permettre la tenue d’études
qui se pencheront sur les façons de maximiser les résultats fonctionnels tout en réduisant
le plus possible la morbidité.
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Article info
Publication history
Published online: November 16, 2021
Accepted:
October 6,
2021
Received in revised form:
July 25,
2021
Received:
September 28,
2020
Footnotes
Presented in part at the Asia-Pacific Vitreoretinal Society Annual Meeting in Seoul, Korea on December 15, 2018.
Identification
Copyright
© 2021 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.
