Tóm tắt Luận án Study on the efficacy of surgical treatment for recurrent retinal detachment

inal detachment 2.2.5.3. Research variables for the results of surgical treatment for RD 2.2.6. Criteria for evaluating research results 2.2.6.1. Clinical characteristics - Visual acuity: we classify into the following groups + From LP to smaller than CF 1 meter. + From CF 1m to <CF 3m. + From CF 3m to 20/200. + From 20/200 to < 20/80. 7 + From 20/80 to 20/40. + From > 20/40 and above - Vision is converted from Snellen table to logMAR table, respectively, to calculate the average value. - Intraocular pressure: Intraocular pressure is measured with a Maclacov tonometer and divided into the following groups: + Low: below 15 mmHg + Normal: from 15 to 24 mmHg + High: above 24 mmHg. - Mechanical symptoms: blurred vision, flying flies, flashing lights or losing sight. Number of previous RD surgeries, recurrence time, surgical methods - Physical symptoms + Anterior section: The anterior chamber is clear or with hemorhage, exudase, vitreous gel... + Posterior section: Retinal detachment area, macular detachment, clinical type of tears, vitrolretinal proliferation. Areas of retinal detachment: Evaluation of retinal detachment areas by quadrant: 1,2,3,4 quadrants or posterior pole retinal detachment. Macular situation: attached or detached. Number of retinal tears Morphology of retinal tear: according to the following 5 forms: o Tear-shaped horseshoe with a flap. o Retinal hole on degenerative background. o Giant tear. o Retinal break o The macula hole. The location of the tear in the quadrant: the tear is located in what kind of quadrant (upper tempral, lower tempral, upper nasal, lower nasal). Tear size: o Minor tear: under 1 hour arc. o Average tear: 1-3 hours arc. o Large tear: over 3 hours arc. Evaluation of vitrolretinal proliferation : according to the classification of the World Retina Society in 1983. Combined lesions: Vitreous hemorhage or choroidal detachment. 2.3.3.2. Causes of recurrent retinal detachment - Reopen the old tear – new retinant tear – vitreous retrolretinant proliferation – silicon oil under retina – macular hole. 8 2.2.6.3. Surgical results - Evaluating retinal attachment results + Attached retina: As clinically and echography retina is is completely attached from centre to periphery after 1 month postop. + Not attached retina: As clinically and echography retina is detached in every level. - Evaluating visual acuity results: Corrected visual acuity was documented at the discharge time and follow up times as same as document before operation . – Evaluating IOP results: IOP was measured by Maclakov tonometer and evaluation as before operation. - Complications: - As peroperation - As soon postoperation - As postoperation later on 6 months - Completement surgery: scleral buckle, inject heavy oil such as PFCL (Decalin) 2.2.7. Data analysis Data were processed by SPSS 18.0 statistical software. Compare the average using the T-student verification algorithm. The qualitative variables are compared proportionally with the test algorithm χ2. The difference is considered to be statistically significant when p <0.05. 2.2.8. Research ethics Chapter 3. RESULT Through a study of 62 eyes on 62 patients with recurrent retinal detachment and treated at the Department of Trauma and Vitreoretinal Department – Vietnam National Ophthalmology Hospital from January 2013 to September 2015, we obtained the following results: 3.1. Patient characteristics 3.1.1 Distribution of patients by age and gender - There are 40 male patients, accounting for 64.5%. 22 female patients, accounted for 35.5%. The difference was statistically significant with p <0.05. The average age is around 49.9 ± 20 with the lowest age being 8 and the highest age being 80. 3.1.2. The interval time for recurrent retinal detachment after the previous surgery About 1-3 months after the previous surgery, there were 47 redetached eyes accounting for 75.8%. In 3 to 6 months, there are 10 9 eyes, accounting for 16.2%, and over 6 months, 3 eyes account for 4.8%. This difference is statistically significant with p <0.05 3.1.3. Time to hospitalization after the first symptoms Patients with RRD usually admitted the hospital in about 1 week, there are 31 patients accounting for 50%, in about 1 week; there are 30 patients who came after 1 month, accounting for 48.4%. The differences between the above groups are statistically significant with p <0.05. 3.1.4. Number of time for previous retinal surgery. The eyes had surgery once, 40 eyes accounted for 64.5%, twice had 18 patients accounting for 29.1%, 3 times accounted for 3.2%, 4 times with 2 accounted for 3.2%. The percentage of the difference between the groups has statistical significance (p <0.05). 3.1.5. Mechanical symptoms Symptoms of blurred vision - 100%. Loss and narrowing of the eyesight were seen in 41 patients (66.7%). Transfiguration symptoms accounted for 25.8%, flashing signs in 6 patients accounted for 9.7%. and 20 patients showed signs of pain. The differences between the above groups were statistically significant with p <0.05. 3.1.6. Functional and physical symptoms 3.1.6.1. Vision condition of the patient upon admission Among CF group <3m, account for 56.5%, 12( 19,4%) patients with HM, patients with visual acuity from CF 3m to 20/200 have 10 patients accounting for 16.1%, vision range 20 / 200 - 20/80 have 1 patient. Visual acuity 20/80 - 20/60 and> 20/60 have 1 patient accounting for 1.6%. 3.1.6.2. The patient's IOP at admission Patients mainly with low IOP 38 patients accounting for 61.3%. Normal eye pressure from 16 - 24mmHg (38.7%) and low eye pressure below 16mmHg. The difference between the levels is statistically significant (p <0.05). 3.1.6.3. Crystalline lens condition The IOL group had 18 eyes, accounting for 29%, the group of remained crystalline lenses had the majority with 40 eyes (64.3%), the group who had the IOL without surgery had 4 patients accounting for 6.5%. The difference between the statistically significant (p <0.05). 3.1.6.4. Vitreous condition - 50 patients (80.6%) were cloudy due to pigmentation - 12 patients (19.4%) were cloudy due to hemorrhage The difference between the 2 groups is statistically significant (p <0.05). 10 3.1.6.5. Areas of retinal detachment Detached retinal area over 2 quadrants accounting for 90,5%, 6 patient have 1 quadrant of detached retina accouting for 9,7%. 3.1.6.6. Macular condition We found that all most of patient have detachment over macular area (89%), 6 patients have macular hole, 13 patients have no detached macular area accounting for 21%. The difference between groups is statistically significant with p <0.05. 3.1.6.7. Retinal lesions * Number of tear: 38 patients with 1 tear accounted for the majority - 61.4%, 3 patients had 2 retinal tears - 8%, and 1 patient had 3 retinal tears accounting for 1.6%. 18 patients have not recorded the tear accounted for 29% * retinal tear location: - Locating on the temporal side accounts for the majority - 73.8% of which the lower temporal side is more. * Retinal tearing and morphology: - 29 tractioned tears is 69,05%, 8 (19,05) tears were caused by peripheral atrophy degeneration, 5(11,9%) macular holes , No case of retinal roof break. 3.1.6.8. Vitreoretinal proliferation The stage C and above group C with 28 patients accounted for 45.1%, 21 groups of vitreoretinal proliferation in stage B, accounted for 33.9% and 13 patients in stage A, accounted for 21.5%. The difference between group is statistically significant with p <0.05. 3.1.7. Subclinical results 3.1.7.1. Ultrasonic Among the 52/62 patients (83.8%) who had an ultrasonic procedure. We found that the status of mobile retina was 59.6%, retina was less and non-mobile accounted for 40.4%. 3.1.7.2.Electroretinography - 57 cases with flat completely ERG were 91,9%, - 5 cases with sever decrease ERG. The difference between two groups is statistically significant with p <0.01. 3.2. Causes of recurrent retinal detachment 3.2.1. The retinal lesions are related to the cause of RRD - Reopening the old tear seen in 12 patients accounting for 19.4%. - New tear seen in 19 patients accounted for 30.6%. 11 - Vitreoretinal proliferation in stage B + C in 49 patients, accounting for 79%. - There are 6 patients with macula (accounting for 9.7%). - 3 patients with silicon oil under retina accounted for 4.8%. The difference between groups is statistically significant with p <0.05. 3.2.2. Related retinal lesions and relapse time According to the study, during the period of 1 to 3 months, there were 39 patients accounting for 46.8% (n = 62), 14 new tears (22.6%), and 9 open old tears (14.5%). At other periods there are less retinal lesions. 3.2.3. Related retinal tears to vitreous causes and retinal causes 47 Tractioned tears and macular holes accounting for 75,8%, 15 Atrophy degeneration tears accounting for 24,2%. The difference between groups is statistically significant with p <0.01. 3.2.4. Related surgical methods to RRD Vitrectomy+ gaz accounting for 40,3%. Drainage fluid + Gaz accounting for 21%. Scleral buckling accounting for 19,4%. Vitrectomy+ Gaz combined scleral buckling accounting for 3,2%. Vitrectomy + silicon oil + scleral buckling accounting for 16.1%. 3.3. Surgical results 3.3.1 Indication of surgical methods for the study patient group - 38 (61,3%) patients selected for vitrectomy + gaz or silicon oil and combined with sclera buckling. - 18 (29%) patients indicated for vitrectomy + gaz or silicon oil - 6 (9.7%) patients indicated for External indentation and drainage fluid under retina detachment. 3.3.2. Surgery results General results: Postoperative results: Generally by three methods, in the first week, 38/62 cases accounted for 61.29% of good retinal reattachment, after 1 month, 51/62 cases accounted for 82.25% of good retinal reattachment cases. After 6 months, except 2 cases of (3.23%), the most of patients was recovered. However, the difference in surgery results between groups was not statistically significant (p> 0.05). - In scleral buckle surgery: At the 1month postop time retina not reattached in 2/6 cases, there fluid under retina. After 2 month postop time all most patient has retina reattached completely 6/6. However the indication for this method is not freequent in RRD treatment: 6/62 (9.7%). 12 - In surgery of vitrectomy + gaz or silicon oil without csleral buckle: At 1 week postop, retina reattached more than others, at 2 months postop it accounted for 94%. - In surgery of vitrectomy +gaz or silicon oil combine with scleral buckle: Retina reattached 30/38 ( 78,9%) postop at 1 month. 3.3.2.1 Correlation of surgery results with patient age Research shows that most of the different age groups are not related to the surgery results, the difference is not statistically significant. 3.3.2.2 Correlation of surgery results with areas of RRD Study shown that areas of RRD ( from 1-3 quadrants) is not related to the anatomical results after operation, the difference is not statistically significant (p=0,2) 3.3.2.3. Correlation between surgery results and the number of tears There is a correlation between the number of retinal tears and surgery results. The difference between groups is statistically significant with p <0.001 3.3.2.4. Correlation between surgery results and the cause of RRD Table 3.22 Correlation between surgery results and the cause of RRD Retinal attachment Cause of RRD Well attached Not well attached χ2 P Number of patient Rate % Number of patient Rate % Reopen old tear 10 90.9 1 9,1 0,686 0,408 New tear 16 94,1 1 5,9 2,257 0,133 Vitreoretinal proliferation stage B+C 42 85,7 7 14,3 1,913 0,167 Macular hole 5 83,3 1 1,6,7 0.005 0.942 Silicon oil under retina 2 66,7 1 33,3 0.525 0.469 We found that there was no statistically significant difference in the causes of BVMTP and the pressure of the retina 3.3.3. Functional results 3.3.3.1. Vision results  Average vision after surgery according to logMAR 13 We found that the average visual acuity before surgery was 2.3 ± 0.6, after surgery, there was a significant improvement: 1.1 ± 0.7, the difference was statistically significant (p <0.0001). By 12 months after surgery, the vision of 54 eyes was improved (87.5%), with the majority of eyes having improved from 2 rows 50 eyes (81%) We noticed that the visual acuity improved significantly from 3 months after surgery. 3.3.3.2. Correlation of surgical methods with visual acuity results The surgical methods related to visual results were statistically different among the groups (p <0.0001). 3.3.3.3. Correlation of retinal detachment over macular and visual acuity result Group of over macular detachment has better VA improvement than the other groups. The defferrenciate between two group is statistically significant with p=0.0001 and reduced at 12 months time with p = 0.01 3.3.3.4. Intracular pressure after surgery The average eye pressure from 15.8 mmHg before surgery increased to 16.8mmHg after surgery. The difference between eye pressure before and after surgery was statistically significant with p <0.001. 3.3.4. Surgical complications 3.3.4.1. Peroperative complications + There were 5 eyes (8.1%) with hemorrhage, 3 eyes (4.8%) choroidal detachment during surgery, 3 eyes (4.8%) having tears caused of vitrectomy touching retina. These retinal tears were treated by photocoagulation and internal indentation (with gaz or silicon oil). + In addition to the 3 cases have a IOL dislocation before surgery 1,9 1,7 1,4 1,1 1,1 0 0,5 1 1,5 2 Ra viện 1 tháng 3 tháng 6 tháng 12 tháng The follow up visual acuity with times Thị lực trung bình Average visual acuity Discharge 1 month 3 month 6 month 12 month 14 3.3.4.2. Early postoperative complications - 8(12,9%) cases having increased IOP after surgery with the highest IOP is 26mmHg. 2 vitreous hemorhage cases at postop. 3 cases IOL dislocation at postop, caused by ruptured posterior capsult. 2 IOL dislocated were adjusted peroperativelly. 3.4.4.3. Late postoperative complications Preretinal membrane on macular area are seen in 5(8.1%)cases. The mean time is from 3 months to 12 months postop. Most of this preretinal membrane is thin so did not cause traction of retina. Vitreoretinal proliferation cause recurrent retinal detachment: 2 cases (4.8%) after 1- 3 month . 4 cases (6,4%) have protruded liquorfied silicon oil to anterior chamber.this complication appeare at 6 months after surgery. Chapter 4. DISCUSSION 4.1. Characteristics of the patient 4.1.1 Characteristics of patients by age and gende - The average age in our study is 49.9 yo According to Coupier L., the average age of having a RRD is 59.4 yo According to Girard P. The average age is 52 yo According to Smiddy W.E. 53 years old is the average age of RRD. - Regarding gender: male account for 64.5%, female account for 35.5%, similar to other authors such as Coupier L. 60.53% and Girard P. 62.02% are male. 4.1.2. The recurrent time after previous RD surgery Most BVM relapse from 2 to 3 months, accounted for 75.8%, as early as 3 weeks and as late as 36 months. equivalent to a number of studies such as Girard P. relapse after 3 months (53.4%), Coupier L. in 51 patients with an average time of about 2.5 months. According to Connrath (2007) at 2.5 months. 4.1.3 Time to hospitalization after the first symptoms After 1 week to 1 month, 48.4% and more than 1 month only have 1 patient. The average time is 2, 3 weeks. Thus, less than 1 month accounted for 98.4% higher than the author Đỗ Như Hơn and Thẩm Trương Khánh Vân (2004) - 56.9%. This is probably due to the patient's awareness and experience of retinal detachment. 4.1.4. Crystalline lens condition 15 In the IOL group, there were 18 patients (29%), while the group with remained crystalline lens had the majority with 40 patients (64.5%), 4 patients had cataract extraction accoounting for 6.5%. According to Chignell A.H. (1973), eye without the crystalline lens is one of the risk factors for failure in the first BVM operation. Girard suppose that group cataract extracapsular extraction had higher reattachment rate than intracapsular extraction group. 4.1.5. Number of previous RD surgery of the patient - 40 eyes were operated once, accounted for 64.5%, the number of eyes was operated twice, accounted for 29.1%, 2 eyes were operated 3 times, accounting for 4.8% and 2 patients had 4 times surgery BVM accounted for 4.8% (p <0.05). Retinal detachment may relapse many times, however, the relapse rate decreases gradually in subsequent surgery, perhaps due to overcoming deficiencies in previous surgery and resolving the cause. 4.1.6. Mechanical symptoms Blurred vision (100%), loss and narrowing of visual field 66.7%, eye flyingflies, and flashes in 6 patients account for 9.7%, symptoms of flying flies 24.2% may be due to pigmentation or hemorrhage. There were 16 patients (25.8%) showing symptoms of seeing colored transfiguration. Pain is a symptom seen in more than 20 patients, perhaps, it was the postoperative sensation of the patient. 4.1.7. Physical symptoms 4.1.7.1. Visual acuity of the patient upon admission In the very low preoperative vision study 2.3 ± 0.6, this is also characteristic of bong võng mạc tái phát. According to the author Đỗ Như Hơn (1996), the recovery of vision until the sixth month after surgery was only 55.8% at CF 3m or less. 4.1.7.2. The intraocular pressure condition upon admission The IOP in the study was low in late patients with high detachment , or large tear. The authors Bonnet M. and Grizzard L. suggested that preoperative low eye pressure is a risk factor for RD surgery failure. 4.1.7.3. The vitreous condition Pigmentary vtreous opacity on 50 patients (80.6%) . Hemorhage vitreous opacity on 12 cases (19,4%). According to Sharma, vitreous opacity with pigment or with hemorhage are the risk of recurrent retinal detachment. 16 4.1.7.4. Area of retinal detahment Area of recurrent retinal detachment all most over on 2 quadrants accounting for 90,5%. According to Matri (2005), over 2 quadrant retinal detchment in RRD accounting for 100%. 4.1.7.5. Retinal lesions * Retinal tears and morphology: Tracion tears in 43 cases accounting for 68.6%. Tears caused by traction of vitreoretinal proliferation. The traction can make a flap of tear, and tear like –shaped horseshoses same as the author Do Nhu Hon patient with traction tears accounting for 63,3%. * Number of retinal tears The team suggests that there may be one or more tears, however. According to Sharma S. and Coupier L. as well as Grizzard L., both realized that the number of retinal tears was not a risk factor for relapse BVM. * Retinal tear position On the temporal side, there are 43 tears, accounting for 73.8%. mainly on the lower temporal side accounts for 50%, which shows that the lower tear is more difficult to treat or the upper tear has been well treated, so only the new tear appears on the lower temporal. 4.1.7.6. Macular condition Allmost patients on the study have lesions on macular area (69.3%), 6 patients have macular hole.. There are 13 patients have no macular detachment. It explains why visual acuity before is very low. 4.1.7.7. Vitreoretinal proliferation Our study encountered 79% eyes with vitreoretinal proliferation on stage B and over C as same as authors Matri (2006) is 90% and Foster ( 2002) is 90%. Acording to Chignell A.H. (1973) vitreoretinal fibrosis is risk factor of the failure surgery statistically. 4.1.8. Subclinical *. Echographic We were able to deploy echo B procedure in 51 eyes, accounting for 82.2%, the rest couldn't be done because of intraocular silicone oil. Sometimes we still clinically see the detachment, but not seen on ultrasonic images. Observing the mobility of the retina under ultrasound helps to predict the difficulty of surgery and surgical results, the high level of detachment accounts for a relatively high percentage - 45.1%, of which the mobile retina, accounts for 33.8% and 11.3% VM is not or less mobile. 17 4.2. Several factors cause of recurrent retinal detachment 4.2.1. Retinal lesions is associated with recurrent retinal detachment Table 4.4 Causes of recurrent retinal detachment by the authors Authors Cause of VRP New tears Reopen old tears Haut J. (1993) 35,9% 33,3% 20,5% S. Limon and H. Offret (1978) 54% 21,4% 32,1% Foster (2002) 80% 50% 30% Bui Huu Quang (2015) 79% 31% 19,4% Vitreorinal proliferation is a main cause of recurrent retinal deachment (79%) same as with study of authors Chignell (1973) Chateris DG. (1995) showed that factors of vitroretinal proliferation in recurrent retinal detachment is 75%. As Haut J. RRD have new tear accounting for 33.3%, as Rachal WF. Burton TC. (1979) reopen tears mainly cause by insuffisan dose of photocoagulation or cryotherapy. According to Scott J. (1986) cause by wrong external indentation accounted for 68,9% and new tear is 18,4% . * Due to retinal lesions in retinal detachment and relapse time At 1-3 months, we encountered all forms of lesions causingrecurrent retinal detachment in which vitreoretinal proliferation accounted for 61.2%. According to Mietz H. (1995), this author claimed that about the second month after the intervention, the formation of vitreoretinal proliferation is usually at the highest level of activity. 4.2.2. Due to tear caused by vitreous factors and retinal factors The group of vitreous cause: retinal tears and macular hole caused by vitreous traction with 45 patients (77.4%).This group is a main cause of retinal tears with changes of vitreous structure and vitreoretinal proliferation. The group of retinal cause: retinal tears on the peripheral retial degeneration encountered for 14 patients (23.3%). As Chignell (1973) và Chateris (1995) the factor of vitreoretinal proliferation on recurrent retinal deachment is 75%. 4.2.3. Correlation between surgical methods and recurrent retinal deachment. We noted that vitrectomy + siliicon oil combine with scleral buckle would be less seen in recurrent retinal detachment: 10 patients (16,1%). 18 Laidlaw AH.(2002) said that it would be good when we have a complementary photocoagulation around the tear before removal of silicon oil.It help decrease RRD rate from 26% down to 14% . The external under retina fluid drainage method with cryotherapy and gaz have 19 patients seen accounting for 21% This rate quite high in group of no vitrectomy method, but if it have complementary scleral buckle we have only seen 12 patients (19.4%). Bonnet (1994) suppose that cryotherapy is a favorable factor for vitreoretinal proliferation postoperation According to Smiddy (1990), handle to retinal adhesion can be related to making a new retinal tear. 4.3. Surgical results 4.3.1. Anatomically We found that most patients after good treatment have a good percentage of retinal pressure, which accounts for the majority of all 3 surgical groups. Of the total 62 surgeries, 2 relapsed after 1.5 months, we found that within 1 week to 1 month, if the retina reattached, the majority of the surgery would have good results. At this stage, if the retina not reattached yet, it will fail. It is necessary to distinguish recurrent retinaldetachment from cases where there is still fluid under the retina after successive retinal detachment surgery, however, there is a persistent part of the sub-retinal fluid, especially in cases of fluid in right at macula makes poor vision improvement. When analyzing different surgical methods, we found that: Scleral buckle method have a high reattachment rate after the first operation. 6/6(100%) Method of vitrectomy and combine with scleral buckle is more frequent indicated for recurrent retiinal detachment and high rate of success reattachment 34/38( 88.8%). At the first week postop, reattachment result of the vitrectomy + gaz or + silicon oil method is fairly good in compare with another method. After 2 months patients of this group have reattached retina 94%. The intraocular indentation with silicon oil group c