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A comparison of 23-gauge and 20-gauge vitrectomy for proliferative sickle cell retinopathy : clinical outcomes and surgical management at Moorfields Eye Hospital

Session Details

Session Title: Vitreoretinal Surgery V

Session Date/Time: Sunday 20/09/2015 | 11:00-13:00

Paper Time: 12:36

Venue: Hermes

First Author: : A.Grabowska UNITED KINGDOM

Co Author(s): :    J. Ho   C. Egan   M. Ugarte   M. Muqit     

Abstract Details

PURPOSE:Patients with sickle cell retinopathy may require operative management to stabilise vision when the macula is threatened by tractional retinal detachment (TRD) or vision is impaired by persistent/recurrent vitreous haemorrhage (VH). We analyse the surgical management and outcomes in a significant cohort of patients who underwent 23G vitrectomy which has supplanted 20G instrumentation over a 6-year period, reviewing indications for surgery, visual and anatomical outcomes and per-operative complications.

Setting:

Moorfields Eye Hospital, an international specialist ophthalmic tertiary referral centre in London, UK, serving a diverse population with a significant Afro-Caribbean ethnic minority. All operations were performed by experienced subspecialist Vitreoretinal Consultants/Fellows across two central operating sites.

Methods:

Retrospective consecutive case series of 72 eyes from 64 patients (35 Male, 29 Female) patients who underwent vitreoretinal intervention for complications of sickle retinopathy based on review of case notes, electronic records and imaging data for all vitreoretinal surgical interventions between 2008-2014. Statistical analysis was performed with GraphPad Prism v6, all results are paired t-tests unless stated otherwise.

Results:

N=72 eyes. 62 cases were HbSC hetereozygotes vs 7 HbSS homozygotes and 3 HbAS (sickle trait) or HbSF (sickle/foetal) with a mean age of 42 years. Indications for surgery were: TRD (25), VH (19), VH with TRD +/– rhegmatogenous retinal detachment (RRD) (11), Macular Hole (MH) / Epiretinal Membrane (ERM) (11), VH and ERM/MH (3), RRD (3). 39 cases underwent 20G vitrectomy whilst 23G surgery was carried out in 33 eyes; the median post-operative follow-up period was 14 months. At the final follow-up, 63 retinae were fully attached, 5 were attached under oil and 4 had a detachment under oil. Overall, mean best corrected visual acuity (BCVA) improved from a pre-operative 1.28 LogMAR (3/60 Snellen) to final BCVA of 0.74 LogMAR (6/33 Snellen) (p=0.000). The subset of 38 eyes with TRD/RRD demonstrated a smaller, non-significant BCVA improvement of 3 lines (p=0.087, NS). Seven particularly challenging cases required primary retinectomy; however this finally yielded no significant improvement in BCVA (p=0.557, NS). 23-Gauge vitrectomy surgery yielded a slightly better 6-line BCVA improvement compared to 5-line improvement with 20-Gauge vitrectomy (p=0.69, NS, unpaired t-test), and was associated with a lower rate of per-operative complications (18% vs 30%, p=0.279, Fisher’s exact test, NS).

Conclusions:

This large comparative case series demonstrates that timely intervention for complicated sickle cell retinopathy can preserve and sometimes improve vision. In agreement with other authors, the degree of improvement/stabilisation in visual acuity remains guarded in tractional/rhegmatogenous detachments in these patients. We have found that this is particularly true in eyes that require primary retinectomy, which can help to manage patient expectations. Our study highlights that advances in technology, 23-Gauge vitrectomy and ever more advanced surgical instrumentation and technique have enabled gradual progress in maximising visual potential for these vulnerable eyes, with lower per-operative complication rates.

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