Pars Plana Vitrectomy Associated with High Retinal Reattachment, but Low Final Vision

Noemi Lois, MD, PhD

Pars plana vitrectomy (PPV) may be an effective strategy to achieve retinal reattachment after tractional retinal detachment in people with diabetes (dTRD), although final postoperative visual acuity (VA) remained low in these patients.

The new findings from a systematic review and meta-analysis report a high primary retinal reattachment rate (94%) following PPV for the treatment of dTRD, with retinal reattachment seen in 99% of eyes with repeated surgery.

“Given that higher preoperative VA was the only factor associated with higher postoperative vision, early intervention should be considered and discussed in detail with patients,” wrote study author Noemi Lois, MD, PhD, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast. “... Although earlier surgery may be helpful, there should be a focus on identifying patients at high risk of developing dTRD and its prevention.”

Despite the introduction of diabetic eye screening programs, as well as improvements in diabetic control and available treatments for proliferative diabetic retinopathy (PDR), individuals living with diabetes often develop severe complications. Numbers suggest 5% of people living with PDR require PPV for tractional retinal detachment despite treatment with panretinal photocoagulation.

Lois and colleagues evaluated anatomic and functional outcomes and complications of dTRD repair by undertaking a systematic review and meta-analysis of existing literature related to the topic. They additionally sought to understand whether baseline patient characteristics and surgical maneuvers were associated with these outcomes.

In doing so, the investigators searched MEDLINE and Embase systematically from January 2000 to February 2022 and additionally screened a reference list of eligible studies. Those considered eligible were published in English, presented outcomes of PPV for nondiabetic TRDs or other vitreoretinal disorders, and included more than 25 eyes.

The main outcomes for the analysis included the rate of failure of retinal reattachment following 1 surgery and final visual acuity (VA). When available, data pertaining to preoperative patient presenting characteristics, surgical maneuvers used during PPV, use of preoperative or intraoperative anti-VEGF injections, and number of surgeries required for retinal reattachment were also retrieved by investigators

After full-text evaluation of the 406 studies identified, 38 (n = 3839 eyes) were found eligible and included for analysis. Patients had a median age of 52.2 years. For those studies reporting sex (31 of 38), data show 1441 were female individuals (50.1%).

The meta-analysis of the overall rate of failure to obtain retinal reattachment after a single surgery included 25 studies (n = 2344 eyes). The pooled estimate of failure was 5.9% (95% CI, 4.1% - 8.3%). The meta-analysis of the overall rate of failure to obtain retinal reattachment after ≥1 surgery included 21 studies (n = 1564 eyes), with a rate of failure of 0.7% (95% CI, 0.2% - 0.3%).

Meanwhile, the meta-analysis of overall final VA included 20 studies (n = 1526 eyes). The pooled final BCVA was 0.94 (95% CI, 0.82 - 1.05) logMAR (approximate Snellen equivalent, 6/53; 95% CI, 6/39 - 6/71).

Utilizing univariable analysis on anatomic outcomes, investigators found 4 of 14 covariates investigated were statistically significantly associated with the risk of failure of retinal reattachment with a single surgery (vitreous hemorrhage, lens status at presentation, use of preoperative or intraoperative anti-VEGF therapy, and instrumentation gauge). The outcomes were investigated further in multivariable meta-analysis, but they were found not to be statistically significant.

Regarding functional outcomes, the data show only baseline VA was significantly associated with final VA (0.66 logMAR worse final vision; 95% CI, 0.41 - 0.93 per 1.0 logMAR worse VA at baseline; P <.001) in a multivariable model. Multivariable analysis revealed no other patient characteristics or surgical variables had a statistically significant association with outcomes, including hypertension.

The study, “Outcomes and Complications of Pars Plana Vitrectomy for Tractional Retinal Detachment in People With Diabetes: A Systematic Review and Meta-analysis,” was published in JAMA Ophthalmology.