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185
Letters to the Editor
Comment on: Sandwich technique using a combination of perfluoropropane and silicone oil for inferior retinal detachment Sir, We read with interest the technique described by Singh et al. [1] for the management of inferior retinal breaks in rhegmatogenous retinal detachment. They describe the combined use of perfluoropropane (C3F8) gas and silicone oil to support inferior retinal breaks. We have a few concerns regarding the proposed technique. First, the role of preexisting proliferative vitreoretinopathy (PVR) changes at the time of presentation has not been considered while describing the indication for using this technique. Inferior retinal detachments with minimal PVR have been shown to settle well with just the use of short‑acting gases such as sulfur hexafluoride (SF6).[2] Second, the role of 240 style encircling silicone band has not been mentioned. Retinal detachments with inferior breaks tend to have superior outcomes when supplemented with an encircling silicone explant.[3] Third, with the proposed upright positioning in this technique, the silicone oil ceases to have any role as soon as the gas starts getting absorbed. This can lead to reopening of the inferior break and promotes the formation of PVR. An underfill of silicone oil further leads to complications such as early emulsification (seen in representative case in Fig. 2 at 2 months), raised intraocular pressure, and corneal decompensation which adversely affect the visual outcome.[4] Two out of the four cases reported had a decline in visual acuity from the preoperative levels. Last, the follow‑up of the cases described is very short to validate the technique. PVR formation has been shown to occur at a median interval of 2 months after surgery.[5] Only one case out of the four has a follow‑up longer than 2 months and that case developed re‑detachment due to PVR. Given the lack of clinical evidence and the poor functional outcomes, this technique needs a reappraisal before it can be put to a widespread clinical use. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Response to comment on: Sandwich technique using a combination of perfluoropropane and silicone oil for inferior retinal detachment Sir, We would like to thank Singh et al. for their interest and valuable comments related to our study.[1,2] Among the four patients, none of the patients had fixed retinal folds i.e., proliferative vitreoretinopathy (PVR) grade C while two patients had
Simar Rajan Singh, Mohit Dogra, Mangat Ram Dogra Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India Correspondence to: Dr. Mangat Ram Dogra, Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India. E‑mail:
[email protected]
References 1. Singh SR, Dhurandhar D, Chhablani J. Sandwich technique using a combination of perfluoropropane and silicone oil for inferior retinal detachment. Indian J Ophthalmol 2018;66:988‑90. 2. Tan HS, Oberstein SY, Mura M, Bijl HM. Air versus gas tamponade in retinal detachment surgery. Br J Ophthalmol 2013;97:80‑2. 3. Storey P, Alshareef R, Khuthaila M, London N, Leiby B, DeCroos C, et al. Pars plana vitrectomy and scleral buckle versus pars plana vitrectomy alone for patients with rhegmatogenous retinal detachment at high risk for proliferative vitreoretinopathy. Retina 2014;34:1945‑51. 4. Toklu Y, Cakmak HB, Ergun SB, Yorgun MA, Simsek S. Time course of silicone oil emulsification. Retina 2012;32:2039‑44. 5. Mietz H, Heimann K. Onset and recurrence of proliferative vitreoretinopathy in various vitreoretinal disease. Br J Ophthalmol 1995;79:874‑7. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/ijo.IJO_1107_18 PMID: ***
Cite this article as: Singh SR, Dogra M, Dogra MR. Comment on: Sandwich technique using a combination of perfluoropropane and silicone oil for inferior retinal detachment. Indian J Ophthalmol 2019;67:185. © 2018 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
presence of PVR grade B. The study by Tan et al. which has been quoted by Singh et al. had excluded the patients with inferior retinal breaks between 4 o’clock to 8 o’clock.[2,3] So a direct extrapolation of their results to our series may not be accurate. In our series, breaks were located in inferior half of fundus in all the patients with case 3 showing multiple inferior breaks, while case 4 was a recurrent retinal detachment with inferior break. We however, agree that cases with primary rhegmatogenous retinal detachment (RRD) with inferior breaks and up to grade B PVR may have a good anatomical outcome even with gas tamponade.[4] The main advantage with our technique is that postoperative prone positioning may not be required.
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186
Indian Journal of Ophthalmology
Volume 67 Issue 1
Table 1: The preoperative and postoperative details of the patients who underwent sandwich technique (14% C3F8) and silicone oil (1000 cs) injection Age/gender
BCVA (preop)
Lens status
Location of break
BCVA (postoperative)
Fundus
Follow up †
6 months
63/female
20/40
Pseudophakic
ITQ
20/125
Retina attached
69/female
20/80
Pseudophakic
ITQ
20/50
Retina attached§
8 months
51/male 46/male
CFCF 20/80
Phakic Aphakic§
Multiple inferior breaks ITQ
20/40 CFCF
Retina attached§ Retina attached§
8 months 14 months
†
Postsilicone oil removal developed reretinal detachment 4 months after the primary surgery. Subsequently, patient underwent revitrectomy with silicone oil injection and at 2 months post resurgery, retina remained stable, §Postsilicone oil removal. ITQ: Inferotemporal quadrant, CFCF: Counting fingers close to face, BCVA: Best‑corrected visual acuity
We did not use scleral explants in any of the eyes. In our study, we intended to study the effect of pars plana vitrectomy alone without the use of any additional procedure like scleral explants. Also, segmental explants may not be needed in all inferior breaks related RRD. As already discussed in the paper, the chorioretinal adhesions start forming in the early postoperative period with maximum strength at 2 weeks. So, we hypothesize that by the time of significant recession of the gas bubble, adequate chorioretinal adhesion would have formed to maintain the retina in position. The concern regarding early emulsification has already been listed as one of the limitations in our study. In order to have more detailed information about PVR changes postoperatively, we revisited our cases since a significant time had elapsed after the primary surgery. The clinical details of the patient are shown in Table 1. Case 4 was a case of recurrent retinal detachment with inferior PVR changes. Post sandwich technique, retina remained attached, however, corneal decompensation ensued. During silicone oil removal, pale disc was noted and thus further surgeries were deferred. The corneal decompensation as seen in case 4 may not be directly related to silicone oil since the patient already had multiple vitreoretinal surgery and was left aphakic. Therefore, silicone oil may not be the sole reason for corneal decompensation in this case. The present report is a “proof of concept” pilot study with small sample size. We wish to plan a randomized study with larger sample size and longer follow up for further validation of this surgical approach. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Sumit Randhir Singh1,2, Deven Dhurandhar1,2, Jay Chhablani1,2 1
Academy for Eye Care Education, LV Prasad Eye Institute, Hyderabad, 2Smt. Kanuri Santhamma Centre for Vitreo‑Retinal Diseases, LV Prasad Eye Institute, Hyderabad, Telangana, India
Correspondence to: Dr. Jay Chhablani, Smt. Kanuri Santhamma Centre for Vitreo‑Retinal Diseases, LV Prasad Eye Institute, Banjara Hills, Hyderabad ‑ 500 034, Telangana, India. E‑mail:
[email protected]
References 1. Singh SR, Dhurandhar D, Chhablani J. Sandwich technique using a combination of perfluoropropane and silicone oil for inferior retinal detachment. Indian J Ophthalmol 2018;66:988‑90. 2. Singh SR, Dogra M, Dogra MR. Comment on: Sandwich technique using a combination of perfluoropropane and silicone oil for inferior retinal detachment. Indian J Ophthalmol 2019;67:185. 3. Tan HS, Oberstein SY, Mura M, Bijl HM. Air versus gas tamponade in retinal detachment surgery. Br J Ophthalmol 2013;97:80‑2. 4. Tanner V, Minihan M, Williamson TH. Management of inferior retinal breaks during pars plana vitrectomy for retinal detachment. Br J Ophthalmol 2001;85:480‑2.
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/ijo.IJO_1290_18 PMID: ***
Cite this article as: Singh SR, Dhurandhar D, Chhablani J. Response to comment on: Sandwich technique using a combination of perfluoropropane and silicone oil for inferior retinal detachment. Indian J Ophthalmol 2019;67:185-6. © 2018 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
