Although rhegmatogenous retinal detachment (RRD) repair techniques have been shown to have high anatomic reattachment rates, discrepancy often exists between the anatomic definition of success and patients’ functional outcomes, explains Rajeev H. Muni, MD, MSc. “Tests used to assess functional outcomes in clinical trials are carried out under specific artificial conditions,” he adds, “and their results may not capture a patient’s quality of vision from a functional perspective. The validated 25-Item National Eye Institute Visual Function Questionnaire (VFQ-25), which assesses vision-related quality of life from the patient’s perspective, may provide a better representation of surgery outcomes compared with any objective test performed in the office.”

Pneumatic Retinopexy Vs Pars Plana Vitrectomy: The Patient Perspective

For a study published in JAMA Ophthalmology, Dr. Muni, Carolina L. M. Francisconi, MD, and colleagues compared vision-related quality of life from the patient’s perspective following pneumatic retinopexy (PnR) with that of those who had undergone para plana vitrectomy within a randomized controlled trial. Participants had RRD and a single break or multiple breaks within 1 clock hour of detached retina in the superior 8 clock hours of the retina with any number, location, and size of retinal breaks or lattice degeneration in attached retina. The VFQ-25 questionnaire—composed of several subscales that assess different aspects of vision-related functioning like driving vision, peripheral vision, and dependency—was completed at 3, 6, and 12 months. “We compared the composite scores and the various subscale scores between the two treatment groups at each time point,” explains Dr. Muni. The study team controlled for factors such as visual acuity in the non-study eye.

“The previously reported Pneumatic Retinopexy vs Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT) demonstrated that patients undergoing PnR had better visual acuity at every time point and less vertical distortion at one year compared to patients undergoing vitrectomy for primary RRD repair,” notes Dr. Muni. “The results of our analysis demonstrate that patients also had better vision-related functioning in several aspects of their daily life in the first 6 months following the retinal detachment repair with PnR compared with vitrectomy.”

Although no differences were observed between the groups at 1 year, after adjusting for age, sex, baseline macular status, visual acuity in the non-study eye, and lens status, “significant differences were found in general vision, distance activities, social functioning, mental health, role difficulties, dependency,  and peripheral vision  at 6 months” in favor of PnR, explains Dr. Francisconi (Table). “It is important to note that several of the VFQ-25 subscale scores had more than a 6-point difference favoring PnR, which is considered a clinically significant disparity.”

Upon multivariate regression assessing the association of the VFQ-25 subscales and Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity, the researchers found that ETDRS was associated will all the subscales, at all time points, after controlling for other factors, such as visual acuity in the fellow eye and treatment group, says Dr. Francisconi. “In other words, the model showed that as ETDRS visual acuity increases, vision-related quality of life scores also tend to increase,” she adds. “Although multivariate regression models do not establish causation, the positive coefficients indicated an association between visual acuity and VFQ-25 subscales.”

Strong Evidence for PnR 

The results of the PIVOT trial, together with this study, provide strong evidence that patients with primary RRD should be offered PnR before vitrectomy for better functional outcomes and better vision-related quality of life in the first 6 months, says Dr. Muni. “We understand that one downside of PnR is the 12% higher risk of requiring a secondary procedure,” he adds, “but this downside is outweighed by the overall better functional outcomes for patients with a PnR first approach.”

References

Vision-Related Functioning in Patients Undergoing Pneumatic Retinopexy vs Vitrectomy for Primary Rhegmatogenous Retinal Detachment
https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2766937?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jamaophthalmol.2020.2007