Korean J Ophthalmol 2017;31(4):328-335

ht tps://doi.org/10.33 41/k jo.2016.0024

pISSN: 1011-8942 eISSN: 2092-9382

Original Article

Impact of Age on Scleral Buckling Surgery for Rhegmatogenous

Retinal Detachment
Sung Who Park1, Han Jo Kwon1, Ik Soo Byon2, Ji Eun Lee1,3, Boo Sup Oum1
1
Department of Ophthalmology, Pusan National University Hospital, Busan, Korea
2
Department of Ophthalmology, Research Institute for Convergence of Biomedical Science and Technology,
Pusan National University Yangsan Hospital, Yangsan, Korea
3
Medical Research Institute, Pusan National University Hospital, Busan, Korea

Purpose: The purpose of this study is to investigate new prognostic factors in associated with primary anatomi-
cal failure after scleral buckling (SB) for uncomplicated rhegmatogenous retinal detachment (RRD).
Methods: The medical records of patients with uncomplicated RRD treated with SB were retrospectively re-
viewed. Eyes with known prognostic factors for RRD, such as fovea-on, proliferative vitreoretinopathy, pseu-
dophakia, aphakia, multiple breaks, or media opacity, were excluded. Analysis was performed to find correla-
tions between anatomical success and various parameters, including age.
Results: This study analyzed 127 eyes. Binary logistic regression analysis revealed that older age (≥35) was the
sole independent prognostic factor (odds ratio, 3.5; p = 0.022). Older age was correlated with worse preopera-
tive visual acuity (p < 0.001), shorter symptom duration (p < 0.001), presence of a large tear (p < 0.001), subreti-
nal fluid drainage (p < 0.001), postoperative macular complications (p = 0.048), and greater visual improvement
(p = 0.003).
Conclusions: Older age (≥35) was an independent prognostic factor for primary anatomical failure in SB for un-
complicated RRD. The distinguished features of RRD between older and younger patients suggest that vitre-
ous liquefaction and posterior vitreous detachment are important features associated with variation in surgical
outcomes.

Key Words: Age, Prognostic factor, Rhegmatogenous retinal detachment, Scleral buckling, Vitreous

Rhegmatogenous retinal detachment (RRD) is a vi- standard treatment for RRD for the past several decades.
sion-threatening disease in which the macula is damaged Previous research has identified several prognostic factors
irreversibly by being detached from the retinal pigment associated with anatomical success after SB [1-5]. The iden-
epithelium. Scleral buckling (SB) was previously the only tified preoperative factors include proliferative vitreoreti-
nopathy [1,2], pseudophakic [3,4], media opacity [1], and
multiple retinal breaks [1,2,5], also known as complicated
Received: March 14, 2016 Accepted: April 12, 2016
RRD; pars plana vitrectomy (PPV) is advocated for these
Corresponding Author: Ji Eun Lee, MD, PhD. Department of Ophthal- cases.
mology, Pusan National University Hospital, #179 Gudeok-ro, Seo-gu,
Busan 49241, Korea. Tel: 82-51-240-7957, Fax: 82-51-242-7341, E-mail:
Vitrectomy is becoming a popular technique for treating
jlee@pusan.ac.kr RRD, while many surgeons empirically use SB as a pri-

© 2017 The Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses
/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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 SW Park, et al. Impact of Age on Scleral Buckling Surgery

mary procedure in young phakic RRD [1,6]. However, require surgical intervention. Final visual outcome was di-
there is no evidence or guidelines for these choices in un- vided into two groups, the logarithm of minimum angle
complicated phakic RRD. resolution (logMAR) score higher or lower than 0.2, as our
The current study was conducted to investigate the prog- database indicated that 0.2 was the median value.
nostic factors after SB in uncomplicated phakic RRD, The primary outcome of this study was the correlation
which excluded known prognostic factors. of preoperative and intraoperative parameters with primary
anatomical success. The secondary outcome was the cor-
relation of various factors with age and final visual outcome.
Materials and Methods Measured decimal VA was converted to logMAR for
statistical analysis. Statistical analysis of univariate cor-
The study was approved by the ethical committee of Pu- relations was performed using Mann-Whitney U-tests, chi-
san National University in accordance with the rules set square tests, or Fisher exact tests. Binary logistic regres-
forth in the Helsinki Declaration. We retrospectively re- sion models were used to identify independent risk factors
viewed the data for consecutive patients diagnosed with for surgical failure. All statistical analyses were performed
uncomplicated fovea-involved RRD in a phakic eye treated using IBM SPSS ver. 21.0 (IBM Corp., Armonk, NY,
with SB and who were followed up for 3 months or more USA), setting the level of statistical significance at p < 0.05.
between January 2011 and December 2012. All patients
agreed to treatment with SB and provided written in-
formed consent. Results
Cases with an attached fovea; history of any intraocular
surgery, including phacoemulsification, obvious vitreous A total of 127 eyes from 127 patients were included. A
opacity, or hemorrhage, multiple breaks (four or more); or summary of baseline characteristics is shown in Table 1.
other ocular diseases affecting visual function were ex- After the first operation, 108 eyes (85.0%) were successful-
cluded. Cases with proliferative vitreoretinopathy of grade ly reattached. Nineteen eyes (15.0%) required a second op-
C were also excluded. eration due to failed primary surgery and were reattached
The preoperative parameters consisted of age, visual without further operation in all cases. Vitrectomy and
acuity (VA), detachment area, symptom duration, refrac- buckle revision were performed as the second operation in
tive error, and presence of a large tear. Detachment area 12 and seven eyes, respectively. Five (3.9%) underwent vit-
was measured as clock hours at the equator. Presence of a rectomy due to macular complications during follow-up.
large tear was defined as a tear with the largest dimension
of 0.5 disc diameters or more. Our database indicated that Table 1. Baseline characteristics
35 years of age was an inflection point, therefore patients Characteristics Value
were sorted into two groups (<35 and ≥35). Age (yr) 38.9 (11−80)
Intraoperative characteristics were evaluated, including Sex (male / female) 67 / 60
subretinal fluid (SRF) drainage and surgeon experience. A Preoperative visual acuity (logMAR) 1.19 ± 0.81
surgeon was classified as experienced if they had surgically
Detached area (hr) 5.9 ± 2.1
treated SB for 5 years or more.
Symptom duration (day) 20.6 (11−80)
Surgical outcomes, such as anatomical success, postoper-
Refractive error (diopter) −3.80 (+3.5 to −14.0)
ative VA, visual improvement, and optical coherent tomog-
No. of breaks 1.6 ± 1.1
raphy findings, were assessed 3 months after SB. Primary
Presence of a large tear
anatomical success was defined as a retina that remained at-
Without a large tear 56 (44.1)
tached for 3 months or more after the first surgery. A small
With a large tear 71 (55.9)
amount of localized f luid in the macula or periphery,
Follow-up (mon) 9.0 ± 6.0
which decreased during follow-up, was not considered sur-
Values are presented as mean (range), mean ± standard deviation,
gical failure. Macular complications referred to a macular or number (%).
hole or epiretinal membrane that was significant enough to logMAR = the logarithm of minimum angle resolution.

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Prognostic factors of primary anatomical success younger age group (p < 0.001). Higher postoperative visual
improvement was observed in the older age group ( p =
Primary anatomical failure occurred more frequently in 0.003), and there was no significant difference in final VA
older patients ( p = 0.042) and those with lower VA ( p = between the two groups. The primary anatomical success
0.005). There was no significant difference in the anatomi- rate was 77.4% in the older age group, which was lower
cal success rates with respect to detached area (p = 0.155), than the 92.3% in the younger age group (p = 0.042). The
symptom duration (p = 0.079), refractive error ( p = 0.220), older age group had shorter symptom duration, less myo-
presence of a large tear ( p = 0.539), or SRF drainage ( p = pic eyes, more frequent large tears, and more frequent SRF
0.240). These findings are summarized in Table 2. drainage than the younger age group. Three cases of mac-
In binary logistic regression analysis, except for preoper- ular hole and two cases of epiretinal membrane occurred,
ative VA, is not considered a single factor, older age (≥35) but only in the older age group (p = 0.048). Sustained SRF
was the sole independent risk factor for primary anatomical was found at 3 months in 26.7% of the older age group
failure (odds ratio, 3.5; 95% confidence interval, 1.201 to versus 51.2% of the younger age group ( p = 0.028).
10.940; p = 0.022). No significant differences in detachment area and fol-
low-up period were observed between age groups.
The impact of age
Prognostic factors of final visual outcome
The impact of age on SB was investigated by comparing
various parameters between the older (≥35) and younger The eyes with better visual outcome (≥20 / 30) had bet-
age (<35) groups (Table 3). ter initial VA acuity (mean logMAR, 1.06; p = 0.035), were
Mean preoperative VA (logMAR) was 1.44 in the older a younger age (mean, 36.3 years; p = 0.045), and had short-
age group, which was significantly worse than 0.94 in the er symptom duration (mean, 13.4 days; p = 0.027) (Table 4).

Table 2. Results of univariate analysis of various parameters for anatomical success after scleral buckle in rhegmatogenous retinal
detachment
Primary anatomical success Primary anatomical failure p-value
No. of eyes 108 (85.0) 19 (15.0) -
Age (yr) 0.042
≥35 48 (77.4) 14 (22.6)
<35 60 (92.3) 5 (7.7)
Initial visual acuity (logMAR) 1.11 1.62 0.005
Detached area (hr) 5.74 6.47 0.155
Symptom duration (day) 23.1 7.3 0.079
Refractive error (diopter) −3.92 −3.20 0.220
Presence of a large tear 0.539
Without a large tear 48 (87.3) 7 (12.7)
With a large tear 60 (83.3) 12 (16.7)
Subretinal fluid drainage 0.240
Yes 80 (82.5) 17 (17.5)
No 28 (93.3) 2 (6.7)
Surgeon’s experience 0.773
≥5 yr 25 (83.3) 5 (16.7)
<5 yr 83 (85.6) 14 (14.4)
Values are presented as number (%).
logMAR = the logarithm of minimum angle resolution.

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 SW Park, et al. Impact of Age on Scleral Buckling Surgery

There was no significant difference in better visual out- Discussion

come with respect to the detached area ( p = 0.058), refrac-
tive error ( p = 0.459), presence of a large tear ( p = 0.152), In the current study, older age (≥35) was the only inde-
or SRF drainage ( p = 1.000) (Table 4). pendent risk factor for anatomical failure after SB for un-

Table 3. Impact of age on various parameters in rhegmatogenous retinal detachment

Older (≥35 yr) Younger (<35 yr) p-value
No. of eye 62 65 -
Age (yr) 55.3 23.2 <0.001
Preoperative visual acuity (logMAR) 1.44 0.94 <0.001
Postoperative visual acuity (logMAR) 0.36 0.37 0.825
Visual improvement (logMAR) 1.08 0.57 0.003
Anatomical success 49 (79.0) 60 (92.3) 0.042
Symptom duration (day) 14.7 23.2 <0.001
Detached area (hr) 5.45 6.23 0.058
Refractive error (diopter) −2.20 −5.32 <0.001
Presence of a large tear <0.001
Without a large tear 13 (23.2) 43 (76.8)
With a large tear 49 (69.0) 22 (31.0)
Subretinal fluid drainage 56 (90.0) 39 (60.0) <0.001
Sustained subretinal fluid 12 (26.7) 22 (51.2) 0.028
Macular complications 5 (8.1) 0 0.048
Values are presented as number (%).
logMAR = the logarithm of minimum angle resolution.

Table 4. Results of univariate analysis of various parameters for final visual acuity after scleral buckle in rhegmatogenous retinal
detachment
Final vision ≥20 / 30 Final vision <20 / 30 p-value
No. of eyes 67 (52.3) 60 (47.6) -
Age (yr) 36.3 41.8 0.045
Initial visual acuity (logMAR) 1.06 1.32 0.035
Detached area (hr) 5.57 6.17 0.058
Symptom duration (day) 13.4 28.8 0.027
Refractive error (diopter) −3.85 −3.78 0.459
Presence of a large tear 0.152
Without a large tear 34 (60.7) 22 (39.3)
With a large tear 33 (46.5) 38 (53.5)
Subretinal fluid drainage 1.000
Yes 50 (52.6) 45 (47.4)
No 17 (53.1) 15 (46.9)
Surgeon’s experience (yr) 1.000
≥5 16 (53.3) 14 (46.7)
<5 51 (52.6) 46 (47.4)
Values are presented as number (%).
logMAR = the logarithm of minimum angle resolution.

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complicated phakic RRD in a binary logistic regression Poor initial vision, less myopic eyes, shorter symptom du-
model, aside from preoperative VA. Although initial VA ration, and presence of a large tear were more common in
also showed a significant correlation with anatomical suc- the older age group. All of these correlations could be ex-
cess on univariate analysis, it may be influenced by multi- plained by vitreous liquefaction resulting in PVD. RRD in
ple factors, and was therefore not considered as a single the young age group showed characteristics of less lique-
factor. Accordingly, VA was excluded from the binary lo- fied vitreous (Fig. 2), which tends to progress slowly and to
gistic regression analysis. have shallow detachment and was reported to show a cor-
Several reports have implied that age is a prognostic fac- relation with better preoperative VA [12]. Less visual loss
tor in RRD repair. Wong et al. [7] reported that older age and slow progression could be related to late recognition
was a negative factor for final anatomical success and func- and longer symptom duration. On the other hand, RRD in
tional success in RRD. Cheng et al. [8], who investigated the older age group (Fig. 3) demonstrated features associ-
surgical outcomes for RRD in high myopic eyes, reported ated with PVD. For instance, they had poor initial vision,
that young age was the only significant factor for anatomi- large tears, and faster progressing bullous RRD, suggest-
cal success using multivariate analysis. However, the pre- ing strong vitreo-retinal traction. Despite poor preopera-
vious studies included heterogeneous patients who not tive VA, visual recovery was greater in the older age group
only underwent SB, but also vitrectomy or combined sur- than in the younger age group that had longer symptom
gery. Our study reaffirmed that age is a significant factor duration, suggesting poor visual recovery [13]. There was no
for anatomical outcomes in SB surgery. difference in postoperative VA between the two age groups.
Park et al. [9] reported that RRD in Korea is character- Postoperative macular complications also support the
ized by the bimodal distribution of the incidence according above explanations. PVD-related complications, such as
to age, with two peak incidence age groups (20–29 years macular hole and epiretinal membrane [14], were only
and 60–69 years), and its inflection was around 35 years of
age. A bimodal pattern was also found in the current study
(Fig. 1) and a study conducted in Germany [10]. Our data
showed a younger peak (20 to 29), which seemed to be as-
sociated with myopia rather than posterior vitreous detach-
ment (PVD) in RRD. Mitry et al. [11] reported that RRD
patients without PVD were younger and more myopic,
supporting our results.
Several characteristics of RRD were evaluated to explain
the correlation between age and anatomical outcomes.

40 Anatomical failure
Anatomical success
30
Fig. 2. Case 1: typical fundus findings of a young patient with
Eye (n)

rhegmatogenous retinal detachment (less liquefied without

20
posterior vitreous detachment, long symptom duration, better
initial visual acuity, small retinal tear, lower visual recovery, and
10 sustained subretinal fluid). A 20-year-old male visited Pusan Na-
tional University Hospital complaining of decreased visual acuity
of his left eye for more than 1 month. His best-corrective visual
0
<15 15–25 26–35 36–45 46–55 56–65 66–75 ≥76 acuity was 20 / 200 in that eye. Fundus photo (left) shows shallow
Age (yr)
retinal detachment (white dotted line) with a small retinal hole
(black line) and a subretinal strand. The retina was reattached af-
Fig. 1. Age of patients with rhegmatogenous retinal detachment. ter scleral buckling without any adjuvant procedure (upper right).
Data shows bimodal distribution with double peaks. Anatomical His best-corrected visual acuity improved to 20 / 50 and optical
failure after primary scleral buckle surgery was observed more coherent tomography (lower right) shows sustained subretinal
frequently in patients older than 35 years (p = 0.042). fluid at 3 months after surgery.

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 SW Park, et al. Impact of Age on Scleral Buckling Surgery

A B

Fig. 3. Case 2: typical fundus finding of an older patient with

rhegmatogenous retinal detachment specified by liquefied with
posterior vitreous detachment, short symptom duration, poor Fig. 4. Theory of vitreous roles in rhegmatogenous retinal de-
initial visual acuity, large retinal tear, better visual recovery, and tachment. Less-liquefied vitreous (A) could play a role as a me-
needed subretinal fluid (SRF) drainage. A 60-year-old male vis- chanical barrier like tamponade that blocks the passage of fluid
ited Pusan National University Hospital complaining of sudden through a break. However, liquefied vitreous with posterior vitre-
visual loss of his left eye 4 days ago. His best-corrected visual ous detachment (B) can counteract the buckle effect.
acuity was measured by counting finger in counting for that eye.
Fundus photo (left) shows bullous retinal detachment (white dot-
ted line) with a large tear of 1.0 disc diameter (black line). The years of age should not be considered as the definitive cri-
retinal tear could not be settled on the retinal pigment epithelium terion for dividing patients by vitreous status or for surgi-
by scleral protrusion. After SRF draining, the tear faced the pig-
ment epithelium due to the buckle effect. His best-corrected vi- cal indication. Furthermore, myopia is more common and
sual acuity improved to 10 / 20 and there was no SRF on fundus more severe in East Asia [20], and thus the current refer-
photographs (upper right) or optical coherent tomography (lower
right) 2 months after surgery.
ence age (35 years of age) might be different in other eth-
nic groups.
The primary SB success rate may be influenced by the
identified in the older age group. The prevalence of devel- study design, which is related to case simplicity, lens sta-
opment of a macular hole after RRD repair was reported tus, or randomization. In retrospective studies, high suc-
to be from 0.5% to 2.0%. Most of these patients (85% to cess rates tend to be reported (as high as 88.8% to 92%)
100%) were over 36 years old [15-17]. Previous studies [7,21,22], while in large randomized prospective studies,
have demonstrated that epiretinal membrane after RRD success rates as low as 63.6% to 80% are reported [3,23].
repair occurred more commonly in old age [18], whereas Lower success rates, from 53.4% to 76%, have been report-
sustained SRF was more frequent in the young age group, ed for pseudophakic eyes [3,4]. The current study retro-
which could be related to long symptom duration [19]. spectively examined phakic eyes and utilized a study de-
The lower primary reattachment rate in the older age sign similar to that of Wong et al. [7] and Miki et al. [21].
group has a number of potential explanations. Non-lique- Our study included the additional criterion of macular-off
fied vitreous could act as a mechanical barrier, blocking RRD, which showed a correlation with low success [24],
the passage of fluid through a break (Fig. 4A). However, and the overall success rate (85.9%) was lower than other
PVD with liquefied vitreous (Fig. 4B) can counteract the similar studies [7,21].
buckle effect. In addition, a stronger traction related with The current study has several limitations, including its
PVD may be prone to a new break. These hypotheses im- retrospective design, short follow-up period, and a small
ply that conserving the vitreous (via SB) would be a better number of patients from a single center. The inclusion cri-
method for less liquefied vitreous, while removing the vit- terion of 3-month follow-up is too short to reflect the final
reous (via PPV) would be better for liquefied vitreous. functional outcome; however, it is likely sufficient to as-
Primary anatomical failure increased dramatically in sess anatomical outcome and may reduce selective bias.
patients over 35 years of age (Fig. 1). Additionally 35 years Although it is expected that direct evaluation of vitreous
of age was the inflection point of bimodal RRD incidence liquefaction would provide more reliable prognostic infor-
in Korea [9]. Therefore, the study population was divided mation, there is no standard method for their accurate
into two groups, above and below 35 years of age, to ana- evaluation of PVD, with the exception of vitrectomy in fo-
lyze the correlation with anatomical success. However, 35 vea off RRD.

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In summary, there was one feature that could differenti- study report no. 7. Acta Ophthalmol 2013;91:282-7.
ate between older and younger RRD: older age (≥35) was 6. Schneider EW, Geraets RL, Johnson MW. Pars plana vitrec-
an independent prognostic factor for primary anatomical tomy without adjuvant procedures for repair of primary
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Further studies are required in order to compare the effica- 2014;34:684-92.
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Conflict of Interest 9. Park SJ, Choi NK, Park KH, Woo SJ. Five year nationwide
incidence of rhegmatogenous retinal detachment requiring
No potential conflict of interest relevant to this article was surgery in Korea. PLoS One 2013;8:e80174.
reported. 10. Thelen U, Amler S, Osada N, Gerding H. Success rates of
retinal buckling surgery: relationship to refractive error and
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