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Original Investigation
April 22, 2021

Postoperative Photoreceptor Integrity Following Pneumatic Retinopathy vs Pars Plana Vitrectomy for Retinal Detachment Repair: A Post Hoc Optical Coherence Tomography Analysis From the Pneumatic Retinopexy Versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial

Author Affiliations
  • 1Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
  • 2Department of Ophthalmology, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
  • 3Kensington Vision and Research Centre, University of Toronto, Toronto, Ontario, Canada
  • 4Keenan Research Centre for Biomedical Science/Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
  • 5Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  • 6Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California
  • 7Department of Ophthalmology, David Geffen School of Medicine at University of California, Los Angeles
  • 8Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia, Canada
  • 9The John and Liz Tory Eye Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 10Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle upon Tyne, England
  • 11Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, England
JAMA Ophthalmol. Published online April 22, 2021. doi:10.1001/jamaophthalmol.2021.0803
Key Points

Question  Does postoperative photoreceptor integrity vary with surgical technique used to repair primary rhegmatogenous retinal detachment?

Findings  In this post hoc analysis of a randomized clinical trial, patients undergoing pneumatic retinopexy had less discontinuity of the ellipsoid zone and external limiting membrane on optical coherence tomography compared to pars plana vitrectomy at 12 months postoperatively. Ellipsoid zone and external limiting membrane discontinuity were associated with worse Early Treatment Diabetic Retinopathy Study visual acuity at 12 months postoperatively.

Meaning  Postoperative photoreceptor integrity can vary with surgical technique, and pneumatic retinopexy is associated with superior photoreceptor integrity at 12 months postoperatively compared with pars plana vitrectomy.

Abstract

Importance  Pneumatic retinopexy (PnR) is associated with superior visual acuity and reduced vertical metamorphopsia compared with pars plana vitrectomy (PPV) for primary rhegmatogenous retinal detachment (RRD). It is important to determine postoperative photoreceptor integrity with both surgical techniques.

Objective  To compare photoreceptor integrity on spectral domain-optical coherence tomography (SD-OCT) between PnR and PPV at 12 months postoperatively.

Design, Setting, and Participants  Post hoc analysis of the Pneumatic Retinopexy Versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT) conducted between August 2012 and May 2017 at St Michael’s Hospital, Toronto, Ontario, Canada. Primary RRDs with specific criteria were included. Data were analyzed between April and August 2020.

Intervention  Randomization to PnR vs PPV stratified by macular status.

Main Outcomes and Measures  Difference in proportion of patients with discontinuity of the ellipsoid zone (EZ) and external limiting membrane (ELM) between groups assessed independently by 2 masked graders at an external masked image reading center.

Results  A total of 150 participants completed the 12-month follow-up visit. A total of 145 patients (72 PPV and 73 PnR) had gradable spectral-domain optical coherence tomography at 12 months. Analysis of the central 3-mm (foveal) scans found that 24% (n = 17 of 72) vs 7% (n = 5 of 73) displayed EZ discontinuity (difference, 17%; odds ratio [OR], 4.204; 95% CI, 1.458-12.116; P = .005) and 20% (n = 14 of 71) vs 6% (n = 4 of 73) displayed ELM discontinuity (difference, 14%; OR, 4.237; 95% CI, 1.321-13.587; P = .01) in the PPV and PnR groups, respectively. Analysis of the 6-mm (foveal and nonfoveal) scans revealed that EZ and ELM discontinuity was greater in the PPV vs PnR groups (EZ, 32% [n = 23 of 72] vs 11% [n = 8 of 73]; difference, 21%; OR, 3.814; 95% CI, 1.573-9.249; P = .002; ELM, 32% [n = 23 of 71] vs 18% [n = 13 of 73]; difference, 14%; OR, 2.211; 95% CI, 1.015-4.819; P = .04).

Conclusions and Relevance  Discontinuity of the EZ and ELM was more common at 12 months postoperatively following PPV vs PnR for RRD repair. The findings of this post hoc analysis suggest that less discontinuity of the EZ and ELM may provide an anatomic basis for the previously reported superior functional outcomes with PnR, although the analysis does not prove a cause-and-effect relationship.

Trial Registration  ClinicalTrials.gov Identifier: NCT01639209

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    1 Comment for this article
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    The role of ILM peeling on EZ and ELM integrity
    Andre Ferreira, MD | Service of Ophthalmology, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
    Dear Editor,
    We read with interest the article titled “Postoperative Photoreceptor Integrity Following Pneumatic Retinopathy vs Pars Plana Vitrectomy for Retinal Detachment Repair” by Muni and associates (1). The authors found a higher prevalence of ellipsoid zone (EZ) and external limiting membrane (ELM) discontinuity at 12 months postoperatively following pars plana vitrectomy (PPV) versus pneumatic retinopexy (PnR) for rhegmatogenous retinal detachment (RRD). We wonder whether there is a strong relationship between the discontinuity of EZ and the ELM after PPV.
    During PPV for RRD, internal limiting membrane (ILM) peeling may reduce the occurrence of epiretinal membrane (ERM) and macular pucker
    after surgery. Fallico et al. (2) conducted a systematic review with meta-analysis that suggested a protective effect of ILM peeling for ERM formation after PPV for primary RRD. Moreover, a lower rate of RRD recurrence was reported (2). However, ILM peeling might damage Muller cells given the presence of interdigitations between ILM and Muller cells footplates (3). As Muni and associates (1) discussed in their work, EZ and ELM integrity may be indicative of photoreceptor health, and discontinuity of ELM may represent absence or regression of Muller cells and irreversible damage to photoreceptors. Thus, ILM peeling may possibly lead to EZ and ELM discontinuity after PPV due to Muller cells damage with consequent disturbance of photoreceptors function.
    In the PIVOT trial (4), there appear to be few specifics regarding ILM peeling. Studies seem warranted to further assess the structural integrity of the outer retina after PPV for RRD with or without ILM peeling, as, to our knowledge, no differences in visual outcomes have been reported when peeling versus non-peeling ILM were compared (2, 5).


    References

    1. Muni RH, Felfeli T, Sadda SR, Juncal VR, Francisconi CLM, Nittala MG, et al. Postoperative Photoreceptor Integrity Following Pneumatic Retinopathy vs Pars Plana Vitrectomy for Retinal Detachment Repair: A Post Hoc Optical Coherence Tomography Analysis From the Pneumatic Retinopexy Versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial. JAMA Ophthalmol. 2021.
    2. Fallico M, Russo A, Longo A, Pulvirenti A, Avitabile T, Bonfiglio V, et al. Internal limiting membrane peeling versus no peeling during primary vitrectomy for rhegmatogenous retinal detachment: A systematic review and meta-analysis. PloS one. 2018;13(7):e0201010.
    3. Gelman R, Stevenson W, Prospero Ponce C, Agarwal D, Christoforidis JB. Retinal Damage Induced by Internal Limiting Membrane Removal. J Ophthalmol. 2015;2015:939748.
    4. Hillier RJ, Felfeli T, Berger AR, Wong DT, Altomare F, Dai D, et al. The Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT). Ophthalmology. 2019;126(4):531-9.
    5. Lim JW, Kim HK, Cho DY. Macular function and ultrastructure of the internal limiting membrane removed during surgery for idiopathic epiretinal membrane. Clin Exp Ophthalmol. 2011;39(1):9-14.


    The authors:
    André Ferreira, M.D., Nisa Silva, M.D., Angelina Meireles, M.D.
    CONFLICT OF INTEREST: None Reported
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