Success Rate Low, Therapeutic Challenges High in Self-Injury Retinal Detachments

The use of a scleral buckle (SB), ideally at first surgery, is significantly associated with superior anatomic and visual outcomes following traumatic rhegmatogenous retinal detachment (RRD) resulting from self-injurious behavior (SIB) in patients with intellectual disabilities, researchers found in the largest international multicenter study on surgical outcomes for these patients. The study,  published in Ophthalmology Retina, included 21 pediatric retina surgeons and co-investigators from 23 centers in the United States, India, Japan, Taiwan, and the United Kingdom.

Traumatic RRD often has poor visual prognosis for individuals with cognitive and developmental delays because of delayed presentation, limited cooperation from the patient, proliferative vitreoretinopathy (PVR) and ongoing ocular trauma from SIB, and intraoperative and post-operative management is challenging for families and doctors who are co-managing the patients, according to the research.

The investigators collected demographic information, type of SIB, systemic diagnoses, clinical histories, preoperative findings, surgical details, final visual acuity and final attachment status on children and adults with RRD from SIB based on review of surgical logs and billing records. Subjects with SIB who had absence of RRD in either eye, open globe injuries as the primary pathology and those with missing outcome data for both eyes were excluded from the study.

Among patients with at least 3 months of follow-up, 23 eyes with retinal detachment (not including phthisical eyes) were deemed inoperable, while 26 of the 81 eyes that were operable at primary surgery underwent vitrectomy only, 21 underwent scleral buckle alone and 31 underwent combined vitrectomy with scleral buckle.

Preoperative assessment found that 36% of SID patients came to ophthalmology clinics due to declined vision or visual behavior, 16.75% came through referral from another ophthalmologist, 21.6% came due to leukocoria, and 12.3% came due to excessive eye rubbing. Evaluations were possible in 45% patients through ophthalmoscopy while 41% of patients needed B-scan ultrasonography, and 32.1% needed to be examined under anesthesia.

The mean duration of the SID on presentation with retinal detachment was 5.8 years and the mean follow-up period was 3.3 years. Bilateral RDs were seen in 26 patients.Another 8 had RD in 1 eye and phthisis bulbi in the other. Of the patients with unilateral RD, 8 developed RD in the fellow eye within the follow-up period, and 42 had bilateral RD and/or phthisis by end of follow-up. 

The researchers found that 31 subjects had more than 1 retinal break, 25 had giant retinal tears, 47 had grade C PVR and or funnel configuration of the RD. Mean baseline logMAR visual acuity in eyes with RD was 3.2 and 2.9 in the fellow eye.

The researchers conducted patient-centered and eye-centric statistical analysis of the 81 eyes of 78 patients (mean age of 15.7 years, 57 males and 21 females) that were deemed operable. The eyes presented with 107 RDs (89 of which were macula-involving, 10 were macular-sparing and 8 were unspecified status). 

The researchers found that of the 78 eyes that underwent surgery primarily, 18 eyes had full (attached without tamponade, including prior oil that was removed, no re-detachment) single surgery anatomic success (SSAS) and 11 had partial (attached post-vitrectomy with permanent oil tamponade) SSAS.

Funnel RD (P =.006) and grade C PVR (subjects, P =.002) on presentation were associated with lower final reattachment and there was a weak association between lower age at presentation and higher rate of redetachment (P =.03). 

SB used as primary surgery was more likely to result in full SSAS compared with solely PPV (47.6% (10 out of 21) for primary SB compared to 11.5% (3 out of 26) for PPV only, P =.009) or the collective group of PPV only and combined SB/PPV (16.1% (5 out of 31) for SB/PPV, P =.005). At final follow-up, after multiple surgeries, the use of a SB at any surgery was more likely to result in partial or fully successful final attachment (87%, 47 out of 54) compared with sole use of PPV (57.7%, 15 out of 26, P =.008).

The researchers noted that a compounding factor for success with SB is that less severe RRDs tend to be amenable to the procedure.

“Scleral buckles provide support for ongoing trauma/traction, are not dependent on positioning, and when added to vitrectomy may offset the effect of incomplete (temporary or permanent) tamponade,” according to investigators. “The presence of anterior PVR and attached hyaloid in the relatively young patient cohort also support the initial use of a scleral buckle. And finally, if primary scleral buckling is possible, risk of certain complications are reduced, including endophthalmitis, intraocular pressure issues, and slower rate of development or progression of PVR compared to failed vitrectomy.”

When oil is left in during PPV, there is a risk of long-term oil complications, so the researchers recommended ongoing monitoring. Simultaneous bilateral surgery is possible for some patients though the surgery carries a higher risk of post-operative complications due to inability to cooperate with post-surgical instructions, the researchers said.

“However, since these cases are under general anesthesia, where systemic risk is increased due to comorbidities, immediate sequential surgery could be considered; in some cases reported here, the induction of anesthesia and the waking out of anesthesia were very difficult and required coordination with intensive care units,” they said.

To minimize risk for infection and pain control, ophthalmologists can consider subconjunctival antibiotics, peribulbar/sub-Tenon’s anesthesia and eye drops as post-operative treatments, the researchers said.

Still, the SIB is likely to continue (only 12.8% of patients in the study reported improvement in SIB at time of follow-up and none reported complete extinction). Identifying and offering interventions for any provoking factors of the SIB is critical, the researchers said. They reported that the various interventions attempted for the cohort included behavioral therapy, occupational/physio/psychological therapy, psychiatric medication, and physical intervention but the interventions led to “very limited improvement in behavior” among the subjects and there was no correlation between behavioral or physical intervention preoperatively or postoperatively and final attachment rate.

“Therefore, our recommendation for pre-operative and post-operative care is to involve the family and a special care team where available prior to proceeding in order to incorporate their individualized recommendation and to use behavioral and physical interventions when it is deemed appropriate by the surgeon, family, and specialty care teams,” the researchers said.

Limitations of the study included the nonconsecutive nature of the case series that could have led to recall bias, the small sample size, the likelihood of confounding study variables, the lack of randomization of surgical approach as it was a retrospective case series, possible confounded result due to differences in the nature of detachment within surgical categories, and the inability to estimate the rate of RRD due to SIB in the population as the patients were selectively reviewed with RRD.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Rossin EJ, Tsui I, Wong SC, et al. Traumatic retinal detachment in patients with self-injurious behavior: an international multicenter study. Ophthalmol Retina. Published online November 22, 2020. doi: 10.1016/j.oret.2020.11.012