|Year : 2018 | Volume
| Issue : 2 | Page : 128-133
An economy-based study: vitrectomy versus scleral buckle for primary rhegmatogenous retinal detachment in poor population
Walid S Ibrahim1, Ahmed H Mohamed2
1 Department of Ophthalmology, Assuit University, Assuit, Egypt
2 Department of Ophthalmology, South Valley University, Qena, Egypt
|Date of Submission||04-Mar-2017|
|Date of Acceptance||06-Jul-2017|
|Date of Web Publication||7-Jun-2018|
Walid S Ibrahim
Department of Ophthalmology, Assiut University Hospital, 71516 Assiut
Source of Support: None, Conflict of Interest: None
Purpose The aim of this study was to compare scleral buckling (SB) and primary pars plana vitrectomy (PPV) for the treatment of primary phakic rhegmatogenous retinal detachment (RRD).
Patients and methods A prospective interventional study was conducted in the Department of Ophthalmology, South Valley University, Egypt, between January 2013 and May 2016. Patients suffering from primary phakic RRD were recruited. Eyes were divided into two groups: the SB group and the PPV group. The SB group underwent radial or encircling silicone sponge retinopexy with cryopexy, and evacuation of subretinal fluid in most cases with air injection. The PPV group underwent three-port 20-G PPV with sulfur hexafluoride or silicone oil (SO) as endotamponade agents. Cost was estimated for the vitreoretinal surgery, cataract surgery, and SO removal. Main outcome measures were anatomical and visual outcome, reoperation rate, and cost of initial surgery and reoperations.
Results Forty-five eyes of 45 patients were included in the present study. Primary anatomical success was achieved in 17 (85%) eyes in the SB group and in 21 (84%) eyes in the PPV group. The final anatomical success rate was achieved in all eyes (100%) in both groups. The final best-corrected visual acuity improved in 14 (70%) eyes in the SB group and in 17 (68%) eyes in the PPV group. Reoperations included retinal reattachment surgery in three (15%) eyes versus four (16%) eyes in the SB and PPV groups, respectively. Cataract extraction with intraocular lens implantation was performed in four (20%) eyes in the SB group versus 16 (64%) eyes in the PPV group, and SO removal was performed in 12 (48%) eyes in the PPV group. SB operation cost was 4960 Egyptian Pounds, whereas PPV surgery cost was 6160 Egyptian Pounds.
Conclusion SB and PPV for the treatment of RRD had comparable results as regards anatomical and functional outcomes. When considering other factors to decide which treatment method is better, such as cost of surgery, SB seems to be of lower cost compared with PPV.
Keywords: silicone oil, surgical cost, vitreoretinal surgery
|How to cite this article:|
Ibrahim WS, Mohamed AH. An economy-based study: vitrectomy versus scleral buckle for primary rhegmatogenous retinal detachment in poor population. Delta J Ophthalmol 2018;19:128-33
|How to cite this URL:|
Ibrahim WS, Mohamed AH. An economy-based study: vitrectomy versus scleral buckle for primary rhegmatogenous retinal detachment in poor population. Delta J Ophthalmol [serial online] 2018 [cited 2018 Sep 20];19:128-33. Available from: http://www.djo.eg.net/text.asp?2018/19/2/128/233929
| Introduction|| |
Rhegmatogenous retinal detachment (RRD) remains an important cause of preventable vision loss. Untreated RRD will lead to severe loss of vision in all patients, in addition to a significant rate of discomfort and cosmetic problems ,. A variety of surgical techniques are available to treat retinal detachment (RD). For primary RD, these procedures have a very high rate of successful anatomic reattachment, including pneumatic retinopexy, scleral buckling (SB), and pars plana vitrectomy (PPV) . Pneumatic retinopexy is practiced in localized superior RD with a single break or more within 1 h ,. SB has been considered the gold standard for uncomplicated RRD ,. PPV was introduced to treat these cases, and, in recent years with marked improvement in such surgery, it became popular as SB procedures ,,. Although there are multiple advantages of PPV over SB surgery, including better detection and localization of retinal pathology, absence of extraocular muscle disturbance, and minimal refractive changes, the use of PPV introduces a new set of potential complications, including entry site break, postoperative nuclear sclerosis, and proliferative vitreoretinopathy ,,.
Many clinical trials and series comparing between SB and PPV for RRD have shown comparable success rates but have encountered factors that are helpful in choosing the most suitable technique for certain subset of patients ,,,,,. These factors may affect a surgeon’s choice of one procedure over another, including personal experience, patient factor, training bias, reimbursement rate, technical difficulty, and so forth ,. Because of the rising costs of healthcare, much attention has been directed toward cost as an important consideration in medical decision making. Few studies comparing cost-effectiveness of retinal attachment surgery techniques have been published ,.
| Patients and methods|| |
A prospective interventional comparative nonrandomized study was carried out on 45 phakic patients with RRD between January 2013 and May 2016.
The study was approved by the Ethical Committee of the Faculty of Medicine of South Valley University. All patients signed an informed consent form. Inclusion criteria were eyes having phakic RD with clear lens, no or grade B proliferative vitreoretinopathy (PVR), and single or multiple breaks. Exclusion criteria were eyes with PVR more than grade B, retinal dialysis, giant retinal tears, ocular trauma, and diabetic retinopathy. All patients underwent determination of best-corrected visual acuity (BCVA), slit lamp examination including anterior segment assessment and clarity of crystalline lens, intraocular pressure (IOP) measurement, and fundoscopic examination to evaluate the extent of RD, retinal breaks as regards their number, type, and localization, and PVR grading.
The clinical examination was performed before surgery and during the follow-up period. All patients were followed-up for 1 year postoperatively.
Patients were divided into two different groups depending on the surgical technique: the SB group (20 eyes) and the PPV group (25 eyes).
After limbal periotomy and passing traction sutures under rectus muscles, retinal breaks were localized. Partial thickness scleral sutures were placed for the buckle to indent the sclera. The surgeon used meridional (radial) buckle in cases with single break and encircling buckle in cases with multiple breaks or total RD. Both radial and encircling buckles were used in selected cases. Silicone sponge explants were selected to support the retina and their sizes ranged from 503 to 507. External drainage of subretinal fluid was performed in most cases and air was injected when eyes appeared hypotonous to maintain the IOP. Retinopexy of breaks was achieved with cryopexy.
Pars plana vitrectomy
A 20-G three-port sclerotomies were performed. A standard vitrectomy was performed to remove the central vitreous, vitreous traction around the break, and peripheral vitreous using wide-angle lenses and scleral indentation. Internal drainage of subretinal fluid was performed through either the break or a retinotomy. Retinopexy was performed using diode laser photocoagulation around the break and the retinotomy site. Fluid–air exchange was performed followed by injection of sulfur hexafluoride 20% or silicone oil (SO) 1000 centistokes for cases of single break and multiple breaks, respectively.
In both groups, all patients were evaluated on the first day, at 1 week, 1, 3, 6 months, and 1 year after surgery. Evaluation was recorded in the information sheets and included the following: BCVA, IOP measurement, lens status, retinal reattachment, and indications for further surgery. Postoperative complications were also recorded.
The cost was estimated for the primary reattachment surgery, second reattachment surgery, cataract extraction with intraocular lens (IOL) placement, and SO removal in eyes that received SO as internal tamponade. The estimated cost was obtained from the Cairo Curative Organization and included surgeon’s fees, anesthesiologist fees, operative room, and the use of the machine whether vitrectomy machine or cryomachine. The authors did not include the cost of preoperative or postoperative medications. The cost of any materials used during surgery, such as silicone sponge, SO, sulfur hexafluoride, and sutures, were added.
BCVA was measured using decimal visual acuity charts and converted to the logarithm of the minimal angle of resolution (logMAR) values for statistical purposes. Patients with BCVA of counting fingers and hand motion were converted to Snellen equivalent according to Holladay hypothesis and were given values of 0.01 and 0.001, respectively. Statistical analysis was performed by using SPSS, version 20 (SPSS Inc., Chicago, Illinois, USA) using independent t-test in quantitative data (e.g. cost) and Pearson’s χ2 for qualitative data (e.g. postoperative redetachment of the retina). In both tests, a P-value less than 0.05 was considered statistically significant.
| Results|| |
This study included 45 eyes in 45 patients; 29 were male and 16 were female patients. The mean age was 52.40±6.81 (range: 40–63) years in the SB group, whereas in the PPV group it was 51.24±6.75 (range: 39–62) years. The macula was detached in 15 (75%) eyes in the SB group and in 18 (72%) eyes in the PPV group. The average number of breaks was 1.55±0.69 (range: 1–3) and 1.68±0.80 in the SB and PPV groups, respectively. The number of quadrants involved was 2.50±1.00 (range: 1–4) in the SB group and 2.60±1.08 (range: 1–4) in the PPV group.
[Table 1] and [Table 2] show that the primary anatomical success was achieved in 17 (85%) eyes in the SB group and in 21 (84%) eyes in the PPV group. The difference in the anatomical success was not statistically significant (P=0.51). The primary anatomical success rate was defined as retinal reattachment 6 months after the primary surgery or 3 months after SO removal. The final anatomical success rate was achieved in all eyes (100%) in both groups.
|Table 2 Postoperative anatomical and functional outcome in the two treatment groups|
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Analysis of the causes of redetachment in the SB group demonstrated extrusion of the buckle 1 month postoperatively in one eye, missed break in the second eye, and PVR in the third eye, whereas in the PPV group the causes of redetachment showed one eye with new break and three eyes with PVR that developed in one of them after the primary PPV and in the other two eyes after SO removal.
At the final follow-up, the BCVA improved in 14 (70%) eyes in the SB group and 17 (68%) eyes in the PPV group. BCVA was 1.04±0.57 preoperatively and became 0.89±0.77 postoperatively in the SB group, whereas in the PPV group the preoperative BCVA was 1.08±0.58 and became 0.79±0.52 postoperatively. There was no statistically significant difference between the two groups ([Table 2]). The mean lines of improvement were 2.15±2.32 (range: 1–7) in the SB group and 2.20±2.68 (range: 1–7) in the PPV group. Again, there was no statistically significant difference between the two groups.
Analysis of the number of reoperations and their indications showed the following. In the SB group, three (15%) eyes with redetachment underwent reattachment surgery with PPV, and four (20%) eyes developed cataract that required cataract extraction with IOL placement. However, in the PPV group, four (16%) eyes underwent PPV surgery due to redetachment, 12 (48%) eyes filled with SO required SO removal, and 16 (64%) eyes with progressive cataract underwent cataract extraction with IOL placement ([Table 3]).
The initial cost of SB operation was 4960 Egyptian Pounds (EGP), which is less costly than that for PPV (6160 EGP) because of the increased cost of materials used during surgery.
The average cost per patient of retinal reattachment surgery was 924 EGP in the SB group and 985.6 EGP in the PPV group.
The number of eyes with cataract progression that required cataract extraction was four (20%) in the SB group and 16 (64%) eyes in the PPV group. Cataract extraction with IOL placement costs 3480 EGP and the average cost per patient was 696 EGP in the SB group and 2227.2 EGP in the PPV group ([Table 4]). The average cost per patient means not every patient underwent each procedure .
|Table 4 Total per patient cost of scleral buckling versus pars plana vitrectomy (Egyptian Pounds)|
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SO was implanted in 12 eyes of the PPV group and required removal during the follow-up. SO removal cost was 1730 EGP and the average cost per patient was 830.4 EGP.
| Discussion|| |
The authors conducted a prospective study to compare SB and primary vitrectomy for treatment of primary RRD. In both treatment groups, there were no statistically significant differences as regards the baseline characteristics such as age and sex.
In this study, the primary anatomical success rate was 85% in the SB group and 84% in the PPV group. Final reattachment was achieved in 100% of the cases. Studies that evaluated these two procedures had a success rate of similar values. Azad et al.  had a success rate of 80.6 and 80% in the SB and PPV groups, respectively, with a final success rate of 100% in both groups. In the phakic trial of SPR (scleral buckling versus primary vitrectomy: rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study) study, the primary anatomical success rate was achieved in 63.6% in the SB group and 63.8% in the PPV group, and the final anatomical success was achieved in 96.7% in the SB group and 96.6% in the PPV group .
Analysis of the causes that resulted in redetachment in the SB group showed that in one eye it was due to early extrusion of the buckle (1 month postoperatively). This may be explained by the large sized (507) radial buckle. Deokule et al.  examined the reasons and outcome of the scleral explant removal. Redetachment occurred in 8.3% of the cases especially within 6 months postoperatively. Brown et al.  postulated that radial sponges have a greater risk for extrusion compared with circumferential ones.
Missed break was found to be the cause of redetachment in the second case. The presence of a missed break as a cause of redetachment was reported in many series .
The third case was due to development of PVR. Goezinne et al.  reported that PVR is a major cause of redetachment especially within the first 6 months postoperatively.
Analysis of the causes of redetachment in the PPV group showed that in one eye it was due to development of a new break. Redetachment after PPV due to open break was reported in other series . Three eyes were redetached due to development of PVR, which occurred after the primary surgery in one eye and after SO removal in two eyes. PVR is a known reason for RRD ,.
In this study, the visual outcome results showed no statistically significant difference between the two treatment groups. The final BCVA improved in 70% of the SB cases versus 68% of the cases in the PPV group. These results are comparable to those of other reports .
Evaluation of reoperation as a factor to decide which treatment arm is more suitable for RD repair was studied in SPR study . In the present series, three (15%) eyes underwent reattachment surgery in the SB group using PPV, whereas in the PPV group four (16%) eyes underwent second PPV for retinal reattachment. In SPR study , the incidence of reoperations for retinal reattachment was 35 versus 53% in the SB and PPV groups, respectively.
In the current study, cataract progression that required cataract extraction was reported in four (20%) eyes in the SB group versus 16 (64%) eyes in the PPV group. Cataract progression after PPV was reported in many series ,. During the period of follow-up, 12 (48%) eyes required SO removal in the PPV group. SO was removed in 53% of the eyes randomized to PPV in the SPR study .
In the current study, the authors selected reattachment surgery, cataract extraction, and SO removal as indications for reoperation. Other reoperations such as additional laser photocoagulation, gas injection, or partial SO removal are minor interventions and may be a subject of bias .
The authors compared cost-effectiveness of SB versus PPV in the present study. The cost of SB was 4960 EGP and that of PPV was 6160 EGP, which means 19.48% saving.
The average total per patient cost, including retinal reattachment, cataract removal, and SO removal was 6580 EGP in the SB group and 10203.2 EGP in the PPV group, which means 35.51% saving. These results suggest a higher cost saving of SB over PPV. Seider and colleagues reported that SB may offer a modest cost saving over PPV with ∼$1655.14 (10.7%) saved per SB procedure.
Until now, there is no consensus as regards the superiority of one procedure over the other for the repair of RD. In previous reports, comparative results were obtained as regards the anatomical and visual outcomes. When reoperations and costs of all surgeries were added to verify which method is better than the other, the decision making may be different. In the current study, the anatomical and functional outcomes were comparable, which agreed with the published reports. In terms of reoperations and costs we found that SB offered a cost saving more than PPV.
Cost consideration has not been a factor in clinical decision making in choosing retinal reattachment treatment . However, when considering the patient’s point of view , particularly in countries of the third world where most of the patients are self-paying, cost saving is an important factor in decision making.
The authors concluded in this small prospective study that both SB and PPV are effective in treating RRD in terms of anatomical and visual outcomes. However, the authors found that the SB was superior to PPV as regards cost saving, which is convenient to our patients.
To the best of the authors’ knowledge, this is the first study to include the cost-effectiveness besides anatomical and functional results to decide which is the better way to fix primary RRD.
Limitations of the present study include the following. The small number of cases is associated with less accurate statistical data. Schwartz et al.  reported that at least 2400 cases are needed to obtain a statistical difference with a P-value less than 0.05. This study is also not randomized, which made the results to be subjected to bias.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]