Systematic review of surgical techniques for treating giant retinal tears in adults: A current assessment of approaches and interventions

INTRODUCTION

A giant retinal tear (GRT) is a full-thickness retinal break that extends 90° or more circumferentially in the presence of posterior vitreous detachment.^[1,2] Approximately 1% of rhegmatogenous retinal detachments (RRDs) are associated with GRT, with an estimated incidence of 0.1 cases/100,000 people per year in the general population.^[2-4] Its incidence is usually greater in males (72%) than in females.^[2] The majority of GRTs have no identifiable cause (idiopathic),^[5] although they can be linked to different factors, such as high myopia, trauma, Ehlers-Danlos syndrome, Marfan syndrome, and hereditary vitreoretinopathies, including Stickler syndrome.^[2,6,7] Moreover, wide areas of lattice degeneration and white without pressure lesions are considered potential risk factors.^[2]

Adult GRTs exhibit changes in their central or core vitreous gel, leading to syneresis and liquefaction. These changes resulted in the formation of large, central lacunae. As the condition progresses, the peripheral gel condenses, and its posterior aspect forms a transvitreal membrane oriented along the equator. Contraction of this membrane causes retinal tearing at the posterior border of the vitreous base. However, vitreous syneresis and liquefaction are not observed in children. This absence is attributed to the presence of type IX collagen, which coats the outer surface of type II collagen within the vitreous. This coating prevents collagen fibrils from adhering to each other and may also account for the robust adherence of the vitreoretinal interface.^[8] In contrast, hereditary vitreoretinopathies and pathological myopia exhibit vitreous liquefaction and fibrillar collagen condensation, indicating the occurrence of GRTs at a younger age.^[8] Although Weinberg et al. reported that the incidence of pediatric RRD due to GRT was 5.6%, a few studies have reported a higher incidence of GRT-associated RRD (15– 20%).^[9,10] However, in adults, the reported incidence of GRT-associated RRD is lower (0.5–8.3%).^[11,12]

Due to the extent of exposure of the retinal pigment epithelium (RPE) the rapid development of pre-operative proliferative vitreoretinopathy (PVR), which increases the risk of redetachment, is believed to be a risk factor for complex redetachment.^[13,14] Common techniques used to treat GRTs include pneumatic retinopexy (PR), scleral buckling (SB), primary vitrectomy with gas or silicone oil (SO) tamponade, and combined vitrectomy with complementary scleral buckling.^[8] Perfluorocarbon liquids (PFCLs) aid in the management of GRTs. Importantly, the advent of PFCLs as transient or temporary (as short- and medium-term agents) tamponades, the use of medical-grade SO, which has physical advantages such as a buoyancy effect and low interfacial tension, faster-speed cutters, the use of vitrectomy systems with improved fluidics and microincision vitrectomy surgery (MIVS) platforms, and the use of peripheral aberration-free wide-field visualization systems has improved anatomical and functional outcomes.^[3,15-18] The final anatomical success rate ranged from 81.8% to 100%.^[16] Although the anatomical success rate is high, the final visual outcome may be restricted due to inherent post-operative complications such as the formation of epiretinal membranes (ERMs).^[19]

This systematic review aimed to elucidate the functional and anatomical outcomes of surgical approaches and interventions for GRT-associated RRDs, focusing on visual acuity improvement, anatomical success rates, and risk factors. This study also aimed to summarize the diversity of surgical techniques involved in its management. We assessed the effectiveness of various techniques in promoting retinal reattachment and visual rehabilitation. In addition, an analysis of the most frequent complications, such as PVR, macular ERM formation (macular pucker), hypotony, cataracts, endophthalmitis, and foreign body reaction, was conducted.

The findings of this systematic study will serve as a significant asset for retinal surgeons by providing recommendations for selecting the most effective surgical approach and interventions for patients with GRTs. Moreover, it identifies specific locations that require additional examinations, thereby fostering future exploration and advancement in the management of this visually impaired illness.

METHODOLOGY

RESULTS

Studies retrieved from database searches

Through electronic searches, we retrieved 4104 unique records, of which 689 were duplicates and 3381 were excluded after screening the titles and abstracts. Thirty-four article abstracts and titles were assessed for eligibility. Twelve studies were excluded for the following reasons: a follow-up period of <6 months, fewer than ten patients, tears with an extent of <90°, or age younger than 18 years. During the screening of the studies, those that did not meet our eligibility criteria also were excluded, resulting in a total of 22 studies^{[2,3,16,18,20-37]} that were selected for full-text screening and synthesis for qualitative analysis in this systematic review [Figure 1]. We contacted the study authors^{[23,25,26,28,38]} in the included studies for further information, but we did not obtain any data from the investigators after waiting for 2 weeks. All included studies were retrospective, and two prospective studies were excluded from the study. The detailed characteristics of the included studies are listed in Table 1.

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Figure 1:

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart of the studies included in this systematic review.

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Table 1: Detailed characteristics of the included studies.

Author and reference number	Number of eyes	Age (years), mean (SD)	Male gender, no. (%)	Study design	Surgical procedure	GRT configuration	Pre-operative visual acuity	Post-operative visual acuity	Follow-Up	Anatomical success
Ramamurthy et al., 2022[36]	240	37 years	339 (86%)	Retrospective	PPV	277 (70%) eyes had configuration of>180° and<270°	20/1500	20/400 and 15% of eyes achieved post-operative VA of 20/60 or better	15 months	Anatomical success after initial surgery was 64% (255 eyes), which improved to 78% (308 eyes) after undergoing a second vitreoretinal procedure for recurrent retinal detachment (53 eyes).
	152				PPV+Encircling band
	4				PPV+SB
Ong et al., 2022[25]	101	N/A	N/A	Retrospective	PPV	N/A	For both children and adults, the mean BCVA at baseline did not differ between the PPV and PPV/SB groups.	For children, mean BCVA at 1 year was better in the PPV/SB than PPV groups (P=0.001). For adults, no difference was found between the 2 groups.	12 months	77.2%
	99	N/A	N/A		PPV+SB	N/A				85.7%
Hocaoglu et al., 2019[34]	45	43.3±13.1	37 (84%)	Retrospective	PPV	≥180°	1.5±1.3	0.46±0.62	37.0±34.8	Overall final reattachment rate was 98%
Chang et al., 1989[17]	23	41.7±11.7	17	Retrospective	PPV	range 3–7 clock h	1.59±0.58	0.84±0.51	12.2±2.7	All patients achieved primary anatomic success of 100%
Bhardwaj et al., 2020[29]	19	41 years	18	Prospective	PPV	90° to 330°	VA ranges from 20/15 to 20/40 in 5 cases (26%), from 20/60 to 20/200 in 5 (26%), and CF or worse in 9 (48%).	• VA was 20/20 to 20/40 in 11 eyes (58%), 20/60 to 20/200 in 7 (37%), and 20/400 in 1 (5%). • 12 eyes in which the macula was detached, 5 (42%) achieved a final BCVA of 20/40 or better.	6 months	Final reattachment rate was 100%.
Kumar et al., 2018[24]	17	25.7	16	Retrospective review	PPV	>180°	2.31±1.27 in adults	0.73 (20/108)±0.38 in adults	10.1 months	Anatomical success was achieved in 88.2% of eyes (n=15/17)
Zgolli et al., 2019[28]	15	45		Retrospective descriptive study	PPV			2/10	9 months	Immediate post-operative anatomical reapplication was achieved in 85% of patients. After 1-year, anatomical reapplication was achieved in 100% of patients.
Mikhail et al., 2017[39]	30	43.7	23	Retrospective consecutive case series	PPV	GRTs had a mean size of 150° (range 90–270°)	1.1 logMAR	70% had an overall improvement in vision, 42 improved by 2 lines, and 35% had 6/12 vision or better.	26.8 months	At final follow-up, the anatomic success rate was 27 of 30 eyes (90%).
Ghasemi Falavarjani et al., 2017[22]	44	33.96±20.19	51	Retrospective study	PPV	42 (67.8) have<180 while 20 (32.2) have>180	2.47±0.79 logMAR	1.43±0.92 logMAR	21.54±27.73	Anatomic success after one vitrectomy procedure was achieved in 45 eyes (72.58%) and ultimately in 61 eyes (98.4%) at last follow up.
	7				Encircling episcleral band (The reason for placing the episcleral band was the age (≤18 years) in 4 eyes)
	18				PPV and phacoemulsification surgery					VA improved in 70%
Al-Khairi et al., 2008[16]	117	30.3±15.2	93	Retrospective study	PPV was performed in all eyes and PPV with encircling buckle was performed in 90 eyes	• 90–180 in 54.4% • >180° in 44.4%	20/200	VA improved in 17.9% from 20/200	29.7±26.7	Success rate with primary procedure was 78.6%, which increased to 94% with multiple surgeries.
Goezinne et al., 2008[18]	30	53.2	26	Retrospective	PPV and PPV with encircling SB was placed in 21 eyes (70%)	• 18 eyes have 3 clock h. • 12 eyes have>4 clock h.	15 eyes have 0.1 while the rest 15 have >15 eyes	13 eyes (43.3%) had a VA of 0.1 or less. VA improved in 54% of the eyes.	49 months	Single operation success is 70% and Final success was 96.4%
Lee et al., 2009[30]	99	39.6 years	113	Retrospective	PPV in all eyes and PPV with encircling SB was performed in 90 eyes	-	-	41 eyes (41.4%) regained 20/40 or better vision. Surgical success for GRT can be achieved with a good visual outcome in 84.8%.	63.38 months	Single operation success was 71.7% and final success was 84.8%
Jain et al., 2014[23]	41	-	-	Retrospective	PPV	-	-	VA improved in 59%	-	Final success was 75%
Pitcher III et al., 2015[26]	54	52	-	Retrospective	PPV alone was performed in all eyes and PPV with SB was placed in 30 eyes (52%)	-	20/500	20/88	17 months,	Single operation success was 88% and Final success was 100%.
Dabour, 2014 [35]	24	37.1±10.6	19	Prospective	PPV with encircling SB	GRT>180	Pre-operative BCVA ranged from HM to CF in macula-off patients, while decimal BCVA in eyes with attached macula was 0.15 in two eyes and 0.05 in one eye.	BCVA improved in 21 (87.5%) eyes, did not change in two (8.3%) eyes, and worsened in one (4.2%) eye.	13.7±6.5	Final success was 83.3%.
Gonzalez et al., 2013[37]	79	43.7	64	Retrospective	All 79 eyes underwent PPV during initial reattachment surgery [Figures 2 and 3]. An encircling SB was utilized in 67 eyes (85%),	The GRT was 90° in 31 eyes (39.2%), >90° but<180° in 30 eyes (37.9%), and≥180° in 18 eyes (22.8%)	• ≥20/40 in 26 eyes (33%). • <20/400 in 48 eyes (61%). • <20/400 in 31 eyes (39%).	• VA was≥20/40 in 17 eyes (22%). • >20/400 in 58 eyes (73%). • >20/400 in 21 eyes (27%). • VA improved in 57%	20.4	Final success was 94.9%
Eiger-Moscovich et al., 2017[40]	13	54±12	11	Retrospective	PPV	-	-	The final BCVA was equal to or better than 20/100.	11±11	6 (60%) had a final BCVA that was equal to or better than the initial BCVA
Randolph et al., 2016[33]	23	50.47±11.12	19	Retrospective	PPV and MT-PFO.	Large retinal break with circumferential measurement of≥90°, or≥3 clock-h	1.01±0.75 logMAR	1.08±0.81 logMAR	33.04±19.74	Successful reattachment was achieved in 91.3% of eyes (21/23) after MT-PFO. Anatomic reattachment was achieved in 91.3% (n=21) of cases after initial staged surgery.
Sirimaharaj et al., 2005[31]	62	44.2	51	Retrospective	PPV	• 90–180° in 45 • 180°–270° in 16>270° in 1	• 6/6–6/12 in 25 eyes • 6/15–6/24 in 1 • 6/36–6/60 in 4 • 6/120 in 3 • CF<<f in 11 • HM in 13 • LP in 5	• VA 6/12 or better in 27 eyes (46.5%). • The VA improved in 34 eyes (54.8%) with 28 eyes (45.2%) improving at least two Snellen lines, it was unchanged in 20 eyes (32.3%), and was worse in eight eyes (12.9%).	24.5 months	At final visit, 58 eyes (93.5%) had retinas that remained attached.
Ambresin et al., 2003[21]	18	43.9 years	13	Retrospective	PPV	• The GRT was 180 degrees or greater in seven eyes. • 90 degrees to 180 degrees in 11 eyes.	N/A	• VA improved in 9 of the 16 eyes. • Remained unchanged in four eyes, and decreased in three eyes	28.6	The retina was attached in 17 (94.4%) of the 18 eyes.
Ünlüet al., 2003[32]	21	33.5 years	17	Retrospective	PPV	• Fourteen eyes (66.7%) had GRT between 90° and 180°. • 7 eyes (33.3%) had tears>180°	VA ranged from 20/40 to light perception	Final VA was equal to or better than 20/200 in 7 eyes (33.3%). VA improved in 15 eyes (71.4%)	12.5 months	Retinal attachment was obtained in 17 (80.5%) of 21 eyes.
Scott et al., 2002[3]	212	41	160	Prospective	PPV in all and PPV with SB was performed in 131 (62%).	• The GRT was 90° in extent in 24 (14%) patients. • >90° in 152 (86%) patients. • >180° in 41 (23%) patients	• 20/80 in 43 (21) • 20/80–20/200 in 13 (6) • 20/400 in 10 (5) • 5/200–CF in 49 (24) • HM, light perception in 91 (44) • No light perception 1 (1)	• 20/200 or better was measured in 67 (47%) patients.	3.8 months	Post-operative visual acuity improved in 107 (59%) eyes, remained stable in 44 (24%) eyes, and worsened in 29 (16%) eyes.

BCVA: Best -corrected visual acuity, CF: Counting fingers, GRT: Giant retinal tear, HM: Hand motion, logMAR: Logarithm of the minimum angle of resolution, N/A: Not applicable, PPV: Pars plana vitrectomy, MT -PFO: Medium -term post -operative perfluoro -n -octane, SB: Scleral buckling, VA: Visual acuity, SD: Standard deviation

DISCUSSION

A search of the relevant literature on the management of GRTs led us to explore various electronic databases to identify studies that assessed the efficacy of different surgical procedures in addressing this complex condition. Despite the significance of GRTs in ophthalmic pathology, we encountered a predominance of retrospective reports and case series in the published literature. Our main objective was to thoroughly examine the extensive and rigorous evidence, specifically focusing on randomized and comparative studies that could provide insights into the comparative effectiveness of different surgical treatments.

To compensate for the scarcity of RCTs and prospective literature on the subject, we expanded our search parameters and selection criteria to encompass pertinent papers published from 2002 onward. Through strategic expansion, we were able to gather a thorough summary of the current literature on GRT management, although it mostly consisted of retrospective and case series research. By adopting this method, we were able to include and examine the existing data, providing valuable insights into the status of research on the management of GRTs during the past 22 years. Furthermore, this study revealed promising areas for future research on surgical therapy for GRTs.

GRT-associated RRDs are uncommon and complex vitreoretinal disorders with a high incidence of potential surgical and inherent complications, which frequently lead to additional surgical procedures and poor functional recovery.^[38] Most available research data originate from nonrandomized studies, with reported primary retinal reattachment rates ranging from 71.7% to 100%.^{[3,6,18,21,24,27,29,30,41]} However, 100% final reattachment was achieved by Bhardwaj et al.^[29] in a small number of patients. In contrast, Ramamurthy et al.^[36] reported anatomical success in 64% (255 eyes) of eyes after primary surgery, which improved to 78% (308 eyes) after a second vitreoretinal procedure for recurrent RD (53 eyes); the observed variability in anatomical success may be affected by patient age.^[42] Additional factors that should be examined in future well-blinded RCTs include the extent of GRT, post-operative tamponade selection,^[32] necessity of adjunctive scleral buckling,^[34,38] use of transscleral diode laser retinopexy,^[29] severity of pre-operative PVR as a main risk factor for anatomical failure,^[36] significance of extensive pre-operative choroidal detachment,^[43] and application of PFO as a short- or medium-term post-operative tamponade.^{[31,33,39,44,45]}

The main problems observed in a thorough examination of the studies that used PFO as a temporary tamponade were cataracts and foreign body reactions. Significantly, postoperative cataract formation has emerged as a significant concern, and its association with the use of PFCL tamponade has been consistently observed in multiple studies. This observation aligns with previous research,^[43] which established a significant association between PFCL use and diverse post-operative complications, including hypotony, macular detachment, and cataract development. Moreover, two distinct studies^[20,33] reported significant foreign body reactions associated with the use of PFO as a short- or medium-term post-operative tamponade. Randolph et al.^[33] reported that the incidence of foreign body reactions was 30.4%, which was substantially greater than that reported in previous clinical trials that used post-operative PFO for retinal detachment.^[44,45] These findings highlight the importance of thoroughly considering and evaluating the use of tamponade agents in retinal procedures, particularly for PFCLs. The difficulties that have been observed, specifically the development of cataracts after surgery and foreign body reactions, highlight the importance of continuously improving surgical techniques and maximizing patient outcomes. These observations enhance our overall understanding of the complexities involved in selecting tamponade options for retinal surgeries and lay the groundwork for future research efforts focused on improving the safety and effectiveness of these procedures.

According to functional and final anatomical evaluations, PVR was the most frequently identified risk factor for disappointing results, followed by circumferential extension of more than 150° of the GRT, low pre-operative visual acuity, pre-operative macular status, the number of detached retinal quadrants, myopia, and age.[2-6,13,16,22,24,35-37]

In summary, it is currently unclear whether there are any possible benefits to treating GRTs by adding an encircling SB and eliminating the advantages of MIVS in selected cases. In line with our research, several studies have discussed the challenge of assessing whether the use of a scleral buckle in conjunction with PPV in GRT surgery can negatively impact the outcomes of the procedure. Due to the absence of information for assessing the risk of bias and inconclusive data from RCTs, it is challenging to draw conclusions from non-randomized research because patient characteristics and the comparability of surgical procedures cannot be determined.^[19,38]

The following are some recommendations for choosing the best surgical strategy and therapy for patients with GRTs, as revealed by the extensive analysis in this study. The most effective surgical technique is the use of 25- or 27-gauge MIVS systems regardless of the extent of the GRT; the placement of complementary scleral buckling is reserved for specially selected patients, such as those with an inferior GRT complicated with severe primary PVR or redetachment with severe anterior PVR; primary PR is rarely used and is indicated for selected superior GRTs without vitreous traction or PVR; the most widely used tamponade is SO; and PFO is safe for use as a temporary tamponade for short or medium periods of time.

This systematic review had several limitations. The main constraint lies in the lack of definitive information obtained from RCTs, which might present difficulties for ophthalmologists when making well-informed judgments to achieve better anatomical outcomes and lower surgical failure rates. Furthermore, research examining past events or studies that are not randomized and lack proper planning is insufficient to answer these questions. Therefore, it is crucial to conduct well-designed RCTs to evaluate the relative benefits of various modern surgical techniques for the treatment of GRTs. One of the main obstacles to making appropriate decisions regarding GRT approaches is the lack of comparative data on surgical techniques for conducting meta-analyses. To address the significant obstacle posed by the lack of comparative data on surgical techniques for GRTs, we recommend conducting well-designed RCTs and establishing a comprehensive, standardized database to facilitate robust meta-analyses. However, it is crucial to provide meticulous post-operative care to address any issues that may arise postoperatively. Despite these limitations, our study showed that when combined with meticulous post-operative care to address post-operative issues, MIVS-based PPV is currently the optimal approach for treating GRTs in adults to improve anatomical and visual results.

CONCLUSION

This systematic review provides a thorough examination of surgical procedures and interventions, highlighting that PPV using 25- and 27-gauge MIVSs is currently the most advantageous surgical method for treating GRT in adults. The findings highlight the variation in visual outcomes after surgery, the success rates in terms of anatomical results, and problems linked to different surgical methods. The prevalence of GRT in males and the influence of age on the effectiveness of surgery emphasize the significance of patient-specific factors. Although anatomical success rates may vary, the occurrence of problems such as PVR, macular pucker, cataract formation, and foreign body reaction highlights the significance of meticulous post-operative care. Additional research and innovation are required to address the gaps and limitations mentioned in the literature and improve the understanding and management of these intricate conditions.