25 gauge Chandelier Illumination-Assisted Scleral Buckling: A Retrospective Study
A retrospective non comparative study was performed in Shanghai Tenth People’s Hospital from June 2013 to June 2014. A total of 41 cases (41 eyes) diagnosed as single break RRD were included and underwent SB surgery using 25-gauge chandelier illumination combined with a non-contact wideangle viewing system. All patients were evaluated with best corrected visual acuity (BCVA), intraocular pressure (IOP), slit lamp biomicroscopy, fundus photography, B-mode ultrasonography and optical coherence tomography (OCT) examination. The study conformed to the Declaration of Helsinki with the permission of the Medical Ethical Committee of Shanghai Tenth People’s Hospital affiliated Tongji University.Surgical Procedure
30 (73.17%) eyes underwent 360 degree band + element surgeries, 4 (9.76%) eyes underwent 360 degree band alone surgeries, and 7 (17.07%) eyes underwent element alone surgeries. External drainage of subretinal fluid was performed in all patients. In 8 eyes, sterile air was used in combination. All surgeries were performed by the same surgeon.360 degree band + element surgery procedures were introduced briefly: 2% lidocaine and 0.75% bupivacaine were mixed and used to induce the retrobulbar anesthesia. Under the surgical microscope, four recti muscles were tagged and the length of 100 mm silicone circling band was placed under the muscles (3mm width, Beijing Jingcheng Medical Devices Co., Ltd, Beijing, China). Subsequently, 25G troca-cannula system with valves (Alcon Laboratories Inc., Fort Worth, Texas, USA) was inserted into vitreous cavity before subretinal fluid drainage. Chandelier illumination (Synergetics Inc., St Charles, Missouri, USA) was usually placed in a quadrant opposite to the retinal breaks. Retinal breaks identification and cryotherapy were performed under the direct visualization through microscope and noncontact wide-angle viewing system (Carl Zeiss Meditec, Jena, Germany) (Figure 1).
Figure 1. Retinal breaks identification and cryotherapy performed under the direct visualization. A retinal break was clearly visualized through microscope and noncontact wide-angle viewing system (A). Preparing for cryotherapy (B). The cryotherapy treatment (C).
Then removed Chandelier illumination, marked retinal breaks, tightened and sutured the encircling band. The average length of encircling band was 68.09±1.51 mm (n=34). Appropriate element was place on the surface of sclera corresponding to retinal break. The location of the retinal breaks were finally confirmed by depressing element under 25G Chandelier illuminations.
There were 22 (53.66%) male subjects and 19 (46.34%) female subjects. The average age was 38.95±18.76 years with a range of 13-70 years. The average duration of RRD was 31.42±54.02 days (range 1-365 days). 17 (41.46%) eyes were emmetropia and 24 (58.54%) myopia, of which 13 (54.17%) eyes were high myopia(≥-6.00DS). 14 (34.15%) eyes were macula-off, 3 (7.32%) eyes were pseudophakic and 7 (17.07%) eyes were long-standing retinal detachment. All patients were followed up for at least 6 months, with a mean period of 8.45±2.40 months.
The primary retinal reattachment was achieved in 40 (97.56%) eyes (Figure 2). The second SB surgery was necessary in 1 (2.44%) eye which failed to completely seal the break. After reoperation, retinal re-attachment was achieved.
Figure 2. A case of RRD which was successfully treated by SB surgery. Preoperative fundus photography (A) and B-mode ultrasonography (C) showed RRD with an horseshoe retinal break in the superior temporal of left eye. Postoperative fundus photography (B) and OCT (D) demonstrated completely retinal reattachment and sealed break.
At the last follow up, 34 (82.93%) eyes had an improved BCVA, 7 (17.07%) eyes unchanged. 28 eyes had a BCVA greater than 0.5, 9 eyes between 0.1 and 0.5, 4 eyes below 0.05 (Figure 3). Among these BCVA unchanged eyes, preoperative and postoperative BCVA was equal to 1.0 in 6 eyes, 1 eye was long-standing retinal detachment with macula detachment.
Figure 3. Changes in preoperative and postoperative BCVA. 34 (82.93%) eyes had an improved BCVA. 28 eyes had a BCVA greater than 0.5, 9 eyes between 0.1 and 0.5, 4 eyes below 0.05. No complications including hemorrhage, retinal damage, elevated intraocular pressure, choroidal detachment and infections occurred during follow-up periods.
Scleral buckling is a very effective procedure in selected cases of RRD such as in young phakic patients . Unfortunately, this technique has been falling out of favor among vitreoretinal surgeons due to the rapid development of vitrectomy technique like sutureless small gauge vitrectomy and wildangle viewing systems. In 2013, United Kingdom National Ophthalmology Database reported 79.1% PPV and 12.1% SB were used in a total of 3403 eyes of primary RRD . Cho et al  also reported the growing trend toward vitrectomy as the preferred primary surgical method for RRD in Korea.
During conventional SB surgery, the fundus is viewed through indirect ophthalmoscope which provides only a small inverted image . It is often difficult to obtain clear visualization especially in posterior capsule opacification, small pupil and a few of vitreous hemorrhage cases. Furthermore, conventional SB technique demands more surgical experience because the surgical procedure for recording and teaching is inconvenient. In recent years, some surgeons have attempted to improve the conventional SB procedures and achieve satisfactory outcomes. Zhong et al  showed that using microscope for SB and trans-scleral cryopexy could visualize the retinal breaks clearly and obtain 92.6% success rates in RRD.
In our study, the success rate of retinal reattachment in initial surgery up to 97.56%, which significantly higher than 53%-85% success rate of conventional SB Surgery . In addition, none of patients occurred any complications associated with Chandelier illumination. In 2012, SB with a noncontact wideangle viewing system was reported and only achieved 81% retinal reattachment in 13 of the 16 eyes . Based on our experience, troca-cannula system with valves could effectively avoid vitreous wicking and maintain intra-ocular pressure. Placing chandelier illumination in the upper quadrant opposite to the retinal breaks made double-handed operation much easier. Gogia et al  obtained 95.6% initial retinal attachment through 25-guage endoillumination in 22 of 23 eyes, which showed a good agreement with our study. Comparing to conventional SB surgery, using 25G Chandelier illumination combination with wild-angle view system had more advantages. First, the entire surgical procedure was performed and recorded under the microscope which convenient for intra-operative or post-operative surgical education. Second, wide view made the retinal breaks and lesions easy to be identified and treated, thereby shortening the operation time. A case demonstrated that RRD with an undetected retinal break preoperatively which was successfully treated by SB through 25-gauge chandelier illumination combined with noncontact wide-angle viewing system . Some doctors concern that endoillumination may disturb the vitreous thus increasing the risk of postoperative complications such as anterior proliferative vitreoretinopathy and endophthalmitis. Our results confirmed that none of the cases occurred any complications during more than one year follow-up period. 27-gauge chandelier, which smaller than 25-gauge, was used to treating pediatric RRD and it might reduce the risk of vitreous wicking and infective endophthalmitis in theory [6, 11].
In summary, SB surgery is still a valid treatment option for RRD. 25-gauge chandelier illumination and non-contact wide-angle viewing system assisted SB surgery has unique advantages and could be used as an additional surgical method to treat RRD.
The authors appreciated all patients participated in this study. This work was supported in part by National Natural Science Foundation of China (Nos. 81300772 and 81271029).
The authors declare that they have no competing interests.
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