Trends and emerging patterns of practice in vitreoretinal surgery.

Abstract

Vitrectomy surgical techniques have rapidly developed over the last 15 years and continue to evolve with the introduction of perfluorocarbon liquids, multifunctional probes, improved endoillumination and sutureless microincision vitrectomy. In the context of rhegmatogenous retinal detachment (RRD) management, there is a decline in buckle surgery (El-Amir et al. 2009) and shift towards pars plana vitrectomy (PPV) as the procedure of choice. Other established indications for PPV include macular hole (MH), epiretinal membrane (ERM), non-clearing diabetic vitreous haemorrhage (NCVH), tractional retinal detachment (TRD) with variations in gases used, posturing regime and vital dyes. The surgical episodes for all patients having vitreoretinal procedures at three sites (St Thomas' Hospital, London Eye Clinic, Queen Mary's Hospital, United Kingdom) under a single surgeon were anonymized and prospectively recorded on an electronic medical record (Vitreor, AxSys Technologies, Glasgow, UK) between January 1997 and December 2013 and is being reported. Included in the study are data on baseline primary indication, details of surgical procedure, method of anaesthesia and intra-ocular agents. Two-sided t-tests and Pearson correlation were performed to test for slope, and all p values are presented with a Bonferroni correction. There were 7570 operations in 5591 patients (1.35 operation per patient), ratio of males to females (1.27:1), the mean age was 59.8 years (SD, 170.0 years), and 48.8% of operations were on left eyes and 51.2% on right eyes. The most common indication for surgery was RRD (42.8%) followed by intervention for vitreous haemorrhage (VH) (12.6%), TRD (6.1%), MH (10.4%) and ERM (7.7%). The relative frequency of vitreoretinal surgical intervention for most indications has remained similar over the past 16 years. In the management of RRD, 82.6% of the cases were pars plana vitrectomy procedures, and 16.6% were external buckle procedures with an increasing pattern towards PPV as the preferred choice (r = 0.229. R2 = 0.052, p < 0.001) (Fig. 1). The percentage of cases undergoing PPV, as compared to explant surgery, has increased from 60% in 1997 to over 90% in 2013. Macular hole surgery increased as a relative proportion of all cases (r = 0.95, p < 0.013) over the 16 years, and there was increasing use of hexafluoroethane (C2F6) as a tamponade agent following its introduction in 2009 rather than perfluoropropane (C3F8: r = −0.508, r2 = 0.252, p < 0.001). This trend in preferential use of C2F6 over C3F8 was also seen for other indications in later years. There was an increasing trend for combined lens and vitreous (CLV) extraction with PPV for the management of ERM and MH (Fig. 1). Brilliant blue is increasingly being used to stain internal limiting membrane in macular pathologies and was preferred over trypan blue. There was a general increasing preference for local anaesthesia across all surgical indications with time (p < 0.001). This study presents one of the largest series in the literature of patients who underwent vitreoretinal (VR) surgery over a prolonged period of 15 years. Overall, this study demonstrates that there is a move towards vitrectomy for both phakic and pseudophakic RRD. It is similar to increasing use of small gauge vitrectomy for the management of primary RRD is seen in many centres around the world (Falkner-Radler et al. 2011; Wong et al. 2014). The role of PPV is likely to further increase over time, as smaller gauge vitrectomy becomes more commonly used, and continuous improvement is seen in anatomical and visual outcomes (Tsang et al. 2008; Falkner-Radler et al. 2011). Our data have shown an increasing incidence of macular hole surgery which has coincided with improvement in optical coherence tomography and vital dyes (Rodrigues et al. 2007). The number of vitreoretinal surgical operations from complications of advanced diabetic retinopathy (tractional retinal detachment and vitreous haemorrhage) has remained constant which may be a reflection of better awareness amongst healthcare providers, improved diabetic control and the establishment of the national diabetic retinopathy screening programme. The study provides useful numbers for the planning of resources for a vitreoretinal service with detail on the pattern of surgical practice and use of various agents required for a vitreoretinal service. Changes in practice include an increased use of small gauge surgery and a resultant reduction in the need for per-operative suturing. Gases and intra-ocular dyes are used regularly, but changes in the agents used with time have been identified. Current trend has major implications on the future education and training of vitreoretinal surgeons and in particular suggests the use of scleral buckle surgery may further decrease in developed nations.