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Surgical management of pseudophakic retinal detachments: a meta-analysis |
Arya A V, Emerson J W, Engelbert M, Hagedorn C L, Adelman R A |
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CRD summary This review evaluated the surgical techniques of pars plana vitrectomy (PPV), scleral buckle (SB) and combined PPV and SB in the management of uncomplicated pseudophakic retinal detachments. The authors concluded that PPV and combined PPV and SB are more successful than SB alone. However, given the methodological limitations, the findings are unlikely to be reliable. Authors' objectives To evaluate pars plana vitrectomy (PPV), scleral buckle (SB), and combined PPV and SB in the management of uncomplicated pseudophakic retinal detachments (PRDs). Searching MEDLINE was searched from 1966 to December 2004 and the bibliographies of retrieved articles screened. Keywords were reported. Studies published in languages other than English, German and French were excluded. Study selection Study designs of evaluations included in the reviewThe authors did not specify what study designs were to be included. Editorials, reviews or letters to the editor were excluded. Small case studies with at most 5 participants were excluded. Details of the designs of the included studies were not reported. Specific interventions included in the reviewStudies that reported the surgical technique of SB, PPV, or both as the initial intervention were eligible for inclusion. Studies in which different techniques were reported for various patients in the same study were included if data could be extracted separately for the different techniques; exceptions were made for 3 studies in which PPV was performed during SB procedures but the outcome data could not be separated. Studies had to report details of surgical procedures to be included. Studies of laser or pneumatic retinopexy were excluded. Participants included in the reviewStudies of patients with PRDs were eligible for inclusion. Studies of patients with complex PRDs (e.g. after advanced diabetic retinopathy, endophthalmitis, or severe trauma), studies in which phakic and pseudophakic RDs were indistinguishable, and those with a preponderance of aphakic patients were excluded, as were those of PRDs in inherited disorders. The mean age of the participants was around 65 years. Outcomes assessed in the reviewStudies that reported anatomical success rates (i.e. retinal reattachment rates) after first and repeat surgeries, and visual success rates (i.e. preservation or improvement of pre-operative visual acuity, or a final visual acuity equal to or better than 20/200) were eligible for inclusion. How were decisions on the relevance of primary studies made?The authors did not state how many reviewers selected studies for the review. Assessment of study quality The authors did not state how they assessed validity. Data extraction The authors stated that data from each study were reviewed twice. Data were extracted on anatomical success rate after first surgery, total reattachmentrate after reoperation for primary failures, visual acuity and the incidence of post-operative proliferative vitreoretinopathy (PVR). In 3 studies where small proportions of eyes that underwent simultaneous PPV and SB surgery (4 to 7%) could not be separated, the data were analysed as SB surgery. Methods of synthesis How were the studies combined?Multivariate logistic regression analysis was used to investigate differences between the procedures investigated. How were differences between studies investigated?The logistic regression analysis was also used to investigate the influence of patient characteristics on the effectiveness of the surgical procedures (mean age, eyes with undetected breaks, intraocular lens characteristics, loss of capsular integrity, macular detachment, prevalence of pre-operative PVR, and secondary surgical interventions by buckle revision or revised PPV). Results of the review Twenty-nine studies (2,230 eyes: 1,579 treated by SB, 457 by PPV, 194 by combined procedures) were included. Twenty-four studies provided data on a single surgical procedure and five were comparative studies of the two different surgical techniques. Twenty-two studies were described as retrospective and seven as prospective.
Anatomical success.
After controlling for variation between study characteristics, PPV and combined PPV and SB demonstrated higher initial attachment rates than SB after first surgery (respectively: odds ratio, OR 1.69, 95% confidence interval, CI: 1.07, 2.68 and OR 3.54, 95% CI: 1.57, 7.97). PPV and combined PPV and SB also demonstrated improved outcomes in comparison with SB after repeat operations such as repeat vitrectomy, buckle revision, or injection of intraocular gas for primary failures (respectively: OR 2.13, 95% CI: 1.05, 4.32 and OR 3.16, 95% CI: 0.99, 10.10). There were no significant differences between PPV and the combined technique for these primary and final anatomical outcomes.
Visual success.
After controlling for variation between study characteristics, the probability of visual improvement was higher after PPV or combined PPV and SB in comparison with SB (respectively: OR 2.34, 95% CI: 1.58, 3.46 and OR 11.52, 95% CI: 4.42, 30.04). Authors' conclusions PPV, or a combination of PPV and SB, was more likely to achieve positive anatomical and visual outcomes than SB alone in uncomplicated PRDs, but data were limited. CRD commentary The review addressed a well-defined question in terms of the intervention and outcomes, but not participants or study design. Only one relevant database was searched, although bibliographies of retrieved articles were screened for English, French and German studies. As the authors stated, publication bias may have been introduced given that unpublished studies were not sought. Although the data were reviewed twice to minimise errors in data entry, the authors did not state how many reviewers were involved in the review process. The validity of the included studies was not assessed, thus the validity of these studies and any synthesis of them is unclear.
The results of these exploratory logistic regression analyses demonstrated that certain surgical techniques are more likely to be associated with positive outcomes. However, the results of comparisons between the surgical techniques may be misleading, given that only some of the included studies appear to have directly compared the surgical techniques. Given the limitations in the search, failure to assess study quality and limitations in the analysis, the results and conclusions of this review should be interpreted with caution. Implications of the review for practice and research Practice: The authors stated that the literature supports the current surgical management of uncomplicated PRDs by vitrectomy techniques rather than by conventional SB alone.
Research: The authors stated that a well-designed randomised controlled trial is needed to compare SB, PPV and the combined procedure for the management of uncomplicated PRDs. Bibliographic details Arya A V, Emerson J W, Engelbert M, Hagedorn C L, Adelman R A. Surgical management of pseudophakic retinal detachments: a meta-analysis. Ophthalmology 2006; 113(10): 1724-1733 Indexing Status Subject indexing assigned by NLM MeSH Aged; Humans; Lens Implantation, Intraocular /adverse effects; Middle Aged; Prospective Studies; Pseudophakia /etiology /physiopathology /surgery; Reoperation; Retina /physiopathology; Retinal Detachment /etiology /physiopathology /surgery; Retrospective Studies; Scleral Buckling /methods; Treatment Outcome; Visual Acuity /physiology; Vitrectomy /methods AccessionNumber 12006007492 Date bibliographic record published 06/06/2007 Date abstract record published 09/08/2008 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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