0
DEPARTEMENT OF OPTHALMOLOGY
FACULTY OF MEDICINE PADJADJARAN UNIVERSITY NATIONAL EYE CENTER CICENDO EYE HOSPITAL BANDUNG
Mini Observational : Characteristic Secondary Glaucoma after Pars Plana Vitrectomy Surgery in Rhegmatogenous Retinal Detachment Patients in Cicendo Eye Hospital in January – June 2020
Presenter : Rizki Fasa Ramdhani Supervisor : Erwin Iskandar, MD
Have been reviewed and approved by Supervisor of Vitreo-Retina Unit
Erwin Iskandar, MD
January 2021
1
CHARACTERISTIC SECONDARY GLAUCOMA AFTER PARS PLANA VITRECTOMY SURGERY IN RHEGMATOGENOUS RETINAL
DETACHMENT PATIENTS
IN CICENDO EYE HOSPITAL IN JANUARY – JUNE 2020 Rizki Fasa Ramdhani, Erwin Iskandar
Vitreoretina Division, Department of Ophthalmology Faculty of Medicine Universitas Padjadjaran
Cicendo Eye Hospital National Eye Center
ABSTRACT
Introduction : Pars Plana Vitrectomy (PPV) is common surgical procedure aimed at removing at removing the vitreous gel with indication for rhematogenous retinal detachment (RRD). Intraocular pressure (IOP) elevation and progressive glaucomatous damage are known postoperative complications following vitreoretinal surgeries.
Purpose : To describe the characteristics of secondary glaucoma after PPV in RRD in Cicendo Eye Hospital on January-June 2020.
Method : An observational retrospective study was undertaken from medical records of patients with secondary glaucoma after PPV in RRD on January-June 2020. A total 29 patients are included in this study.
Result : The mean age of this study was 48 ± 7.98 years old with most of patients 20 people were male (69%). All patients underwent PPV without scleral buckle and Silicone Oil (SO) 1000 cSt was the most used tamponade in this study (82.76%). Secondary glaucoma developed in 17 patients (58.62%) less than 1 month after PPV. All patients treated with antiglaucoma drugs and 11 patients underwent glaucoma surgery (37.93%). Nine patients (31.03%) had IOP
<22mmHg on the last follow up.
Conclusion : IOP measurement after pars plana vitrectomy is important to monitor and prevent unintentional high IOP. We observed higher IOP postoperatively in males, in those under 50 years old, and highest IOP peak occurred less than 1 month.
Keyword : Pars Plana Vitrectomy, Secondary Glaucoma, Rhegmatogenous retinal detachment.
INTRODUCTION
Pars Plana Vitrectomy (PPV) is common surgical procedure aimed at removing at removing the vitreous gel with indication for retinal detachment, macular puckers and holes, diabetic retinopathy and trauma. Replacing the vitreous gel with a variety of substances
denominated tampons and including silicone oil, gases, and perfluorocarbon liquids has shown the potential to significantly alter ocular pressure both acutely and chronically.1,2
Silicone oil (SO) was introduced by Cibis for vitreoretinal surgery, and it was used for
intraocular tamponade owing to its buoyant force and its high surface tension. It has been associated with complications including cataract, keratopathy, anterior chamber oil emulsification and glaucoma.
Intraocular pressure (IOP) elevation and progressive glaucomatous damage are known postoperative complications following vitreoretinal surgeries. Retinal detachment had reportedly 4 -12 times higher prevalence of Primary open angle glaucoma (POAG) than general population. Prevalence of myopia as a common risk factor for both disease.1,3
The purpose of this study is to describe the characteristic secondary glaucoma who underwent pars plana vitrectomy in rhegmatogenous retinal detachment (RRD) in January-June 2020.
METHOD
We performed a retrospective review from the medical records of the patients who underwent PPV in RRD patients from Vitreoretinal Unit Cicendo Eye Hospital, Bandung, Indonesia, between January 1st to June 31st 2020.
Inclusion criteria were patients Secondary Glaucoma after PPV with indication RRD and followed up until December 2020. Exclusion criteria was Previous history of glaucoma before surgery.
The clinical information of the patients were collected from medical records, including age, sex, IOP before PPV surgery, posterior segment condition such as grade of proliferative vitreoretinal and number of quadrant retinal detachment, complimentary
diagnosis, types of retinal surgery and tampons used, SO duration, SO emulsification and onset of secondary glaucoma.
Definition of secondary glaucoma is increase IOP > 21 mmHg. The IOP measured included the IOP at first time increasing and 1-month post treatment. Data in this study was analyzed using Microsoft Excel 365.
RESULT
The total of PPV with indication ARR in Cicendo Eye Hospital was 267 in period January to June 2020.
Base on inclusion and exclusion criteria the number of subjects were included in this study was 29 patients. Preoperative and intraoperative characteristics of the 29 patients are summarized in Table 1. The mean age of this study was 48
± 7.98 years old with most of patients 20 people were male (69%).
The mean IOP before surgery was 12.59 ± 6.00 mmHg. The most of patient had myopia gravior 7 (24.13%) patients, PVR gr B 16 (44.17%) patients and Retinal detachment in 3 quadrant 12 (41.38%) patients. In this study all patient undergo PPV without scleral buckle. There is 7 patients (24.13%) had been done vitrectomy surgery before. SO 1000 centistokes (cSt) was the most SO used in 24 patients (82.76%).
In Table 2 shows the onset of secondary glaucoma occurred at 1 days postoperative and mostly at more than 1 month postoperative in 12 patients (41.38%) with mean of the onset at 53 days. SO emulsification occurs at 11 eyes (37.93%). The first peak of IOP in first onset secondary glaucoma in
group 24-48 mmHg with mean the IOP was 39.60 mmHg.
Table 1 Characteristics of Patients
Variables N (%)
Mean Age, years (SD)
48 + 7.98
Sex
Male 20 69%
Female 9 31%
IOP before Surgery
12.59±6.00 Complimentary
Diagnosis
Myopia Gravior 7 24.13%
Pseudophakic 2 6.89%
Aphakic 2 6.89%
Uveitic 2 6.89%
Number of Surgery
1 22 75.87%
>1 7 24.13%
PVR
PVR gr A 3 10.34%
PVR gr B 16 44.17%
PVR gr C 1 3.45%
Total Quadrant of retinal detachment
1 Quadrant 1 3.45%
2 Quadrant 6 20.69%
3 Quadrant 12 41.38%
All Quadrant 10 34.48%
Type of Surgery PPV + SO 1000 cSt
24 82.76%
PPV + 5000 cSt 3 10.34%
PPV + Heavy SO 1 3.45%
PPV + C3F8 1 3.45%
SD: standar deviation, IOP: intraocular pressure, PPV: pars plana vitrectomy, SO:
silicone oil, cSt: centistokes, C3F8:
perluoropropane, PVR: proliverative vitreoretinopathy
Table 2 Characteristics of Secondary Glaucoma
Variables n (%)
Onset Glaucoma
1 day 3 10.34%
1 week 4 13.8%
1 month 10 34.48%
> 1 month 12 41.38%
SO duration (week)
<4 0
4-12 1 3.45%
12-24 8 27.59
24-48 19 65.51%
>48 1 3.45%
SO
emulsification
11 37.93%
First Peak IOP (mmHg)
22-30 6 20.69%
31-40 10 34.48%
41-50 10 34.48%
>50 3 10.35%
Therapy for secondary glaucoma can be done with medicamentosa and surgery. All the patients with secondary glaucoma in the first onset were given antiglaucoma drugs to reduced the IOP. A total of 24 patients (82.75%) performed evacuation SO, 2 patients performed vitrectomy surgery with redetachment retina, and 3 patients had retained SO. Trabeculectomy is performed in 9 eyes (31.03%) and 3 patients performed trabeculectomy after evacuation SO. A total of 1 (3.45%) trabeculectomy using 5- Fluorouracil (5-FU) and transscleral cyclophotocoagulation (TSCPC) performed on 1 eyes (3.45%). A total of 16 patients (62.06%) only SO evacuation, 2 patients (6.89%) performed vitrectomy surgery, 10 patients (34.48%) SO evacuation and glaucoma surgery, 1 patients (3.45%) only performed glaucoma surgery,
and 2 patients (6.89%) only used antiglaucoma drugs. 18 patients (66.67%) had 2 antiglaucoma drugs.
The IOP in 1 month after treatment in group less than 21 mmHg 9 patients (31.03%) and group 22-30 mmHg (31.03) with mean the IOP was 28.2 mmHg.
Table 3 Treatment
Variables n (%)
IOP 1 month after therapy (mmHg)
<21 9 31.03%
22-30 9 31.03%
31-40 5 17.25%
41-50 4 13.8%
>50 2 6.89%
Evacuation SO 24 82.75%
Vitrectomy Surgery
2 6.89%
Retained SO 2 6.89%
Glaucoma Surgery
None 18 62.06%
Trabeculectomy 9 31.03%
Trabeculectomy + 5FU
1 3.45%
TSCPC 1 3.45%
Amount of Drugs after second surgery
0 5 18.52%
1 3 11.11%
2 18 66.67%
3 1 3.7%
DISCUSSION
There are 29 patients with secondary glaucoma after vitrectomy surgery in Januari to June 2020. The mean age of this study was 48 ± 7.98 years old with most of patients 20 patients were male (69%). Pillai et al reported patients less than 50 years old had significantly increased risk of developing IOP after vitrectomy
surgery because younger patients had heightened inflammatory response in anterior chamber.2 Antoun et al reported 66.1% were male patients.
in retinal detachment.1 Highly myopic eyes become risk for retinal detachment and risk for acute IOP rise due to anterior shifting of the iris-lenticular diaphragm after PPV.
In this study reported 7 patients (24.13%) had myopia gravior.
Antoun et al reported 10 patients (16.1%) had myopia gravior. The mean preoperative IOP in this study was 12.59 ± 6.00 mmHg (range 5-21 mmHg). Antoun et al reported the mean preoperative IOP was 13.38 ± 6.8 mmHg (range 5-27 mmHg).1 Kovacic et al reported the mean preoperative IOP 14.2 ± 4.9 mmHg.4
In this study most patient had 3 quadrant retinal detachment in 12 patient (41.38%) and PVR gr B in 16 patients (44.17%). Xu et al reported increase IOP with PVR grade ≥ C2 (55.56%) than in PVR gr < C2 (34.21%).5
All patient undergo PPV without scleral buckle. SO 1000 centistokes (cSt) was the most SO used in 24 patients (82.76%). PPV in RRD had over 5 times risk to developed secondary glaucoma.2 Silicone oil is an effective intraocular tamponade that had been used in the treatment of RRD associated with PVR. PPV with C3F8 or SF6 gas tamponade is the method of choice for treating primary uncomplicated RRD.
However, the use of SF6 or C3F8 gas must be avoided in patients living in high altitude because variation in atmospheric pressure associated with altitude can cause an expansion of the gas bubble and acute increase in IOP
postoperatively. In this study there is 1 patients with C3F8 gas tamponade increasing IOP in 1 week postopertively. Xu et al reported 47.17 % patients with gas tamponade had higher risk in increase IOP in early postoperatively. SF6 volume can expanded 2 times in 24-48 hours and C3F8 can expanded in 48-72 hours postopertively.5,6 However, Pillai et al reported 34.9 % patients developed a rise in IOP with silicone oil implanted than 11.94% with air or gas implanted.2
The pathogenesis in increased IOP differentiate with acute or chronic mechanism. Preexisting glaucoma, SO in the anterior chamber, previous vitreoretinal procedures, and overfilling have been associated with acute elevated IOP.1,3,7 In this study, previous history glaucoma are excluded and there is 11 patients 37.93% had SO emulsification, and 7 patients (24.13%) have a previous history vitreoretinal procedures. In this study reported increase IOP after surgery 17 patients in total 1 months after surgery with 3 patiens (10.34%) at 1 day postopertively, 4 patients (13.8%) at 1 week postoperatively, and 10 patients (34.48%) at 1 month postoperatively. Pillai et al, reported increase IOP at 1 day postoperatively 17.21%, at 1 week postoperatively 38.41%, and 1 month postoperatively 27.81%.2 Antoun et al reported 35 patients (56.5%) had increased IOP in the follow-up and mostly during the first month postoperative.1
Chronic IOP elevation after PPV mostly refers to the development of open angle glaucoma by oxidative theory that leading to trabecular meshwork damage. Liu et
al reported there is increasing IL-17, IL-6 and TNF-α in aqueous humor samples in evacuation SO (average time 10.8 ± 7.1 months).8 In this study 12 patients (41.38%) had increasing IOP in more than 1 month with mean duration of SO tamponade was 27.8 ± 7.82 weeks. Antoun et al reported mean duration of SO tamponade was 5.12 ± 2.37 months (range 2-12 months).1 Pillai et al reported 21.87% had their peaks between 1 and 3 month and 21.87%
from 3 months postoperatively. In this study, the most of patients had a increased IOP after PPV in more than 30 mmHg is 23 patients (79.31%) with the mean 40.69 mmHg in the follow up. Kevocic et al reported the IOP increased with 3 mmHg after PPV with retinal detachment.4
Medical therapy are usually successful in controlling IOP after vitrectomy surgery. It is reported 78% patients with glaucoma after PPV and silicone oil injection were treated successfully with medication alone.7 In this study 18 patients (62.06%) had medication alone.
However, some develop synechial angle-closure glaucoma with uncontrolled IOP requiring surgical intervention. Trabeculectomy with mytomicin C is a widely performed glaucoma surgery.7 In this study 9 patients (31.03%) underwent trabeculectomy procedure with 2 patients underwent trabeculectomy after SO removal and 6 patient trabeculectomy with SO removal simultaneously. Cyclodestructive procedure have been used but it had irrersible and frequently unpredictable IOP lowering effects.7 In this study 1 patients underwent
TSCPC because developed in neovascularization glaucoma. In this study reported 9 patients (31.03%) had IOP less than 21 mmHg and 18 patients (66.67%) need 2 antiglaucoma drugs for reducing the IOP. Antoun et al reported 88%
patients responded to antiglaucoma drugs, 3 patients (8.6%) had a good control IOP after evacuation SO at 3 months and 1 patients (2.9%) was not controlled after SO removal and required a trabeculectomy. In this study, after the treatment by antiglaucoma drugs or surgery the most of patients had IOP in less than 21 mmHg is 9 patients (31.03%) with the mean 29.4 mmHg.
CONCLUSION
Secondary glaucoma is a common complication after pars plana vitrectomy. IOP measurement after vitreoretinal surgery is important to monitor and prevent unintentional high IOP. After PPV there is higher IOP elevation in males, those younger than 50 years in case RRD.
Highest IOP peaks occurred in less than 1 month.
REFERENCE
1. Antoun J, Azar G, Jabbour E, Kourie HR, Slim E, Schakal A, et al. Vitreoretinal surgery with silicone oil tamponade in primary uncomplicated rhegmatogenous
retinal detachment.
2016;36(10):1906-12.
2. Pillai G, Varkey R, Unnikrishnan U, Radhakrishnan N. Incidence and risk factors for intraocular
pressure rise after
transconjunctival vitrectomy.
Original Article. 2020 May 1, 2020;68(5):812-7.
3. Rossi T, Ripandelli GJJoCM. Pars Plana Vitrectomy and the Risk of Ocular Hypertension and Glaucoma: Where Are We?
2020;9(12):3994.
4. Kovacic H, Wolfs RC, Kılıç E, Ramdas WDJBo. The effect of multiple vitrectomies and its indications on intraocular pressure. 2019;19(1):175.
5. Xu P, Xia T, Chen JJJCEO. Early Postoperative Intraocular Pressure Elevation after Vitreoretinal Surgery. 2017;8(636):2.
6. Zhou Y, Zhang S, Gao M, Zhou H, Liu H, Sun X. Different tamponade effects of intraocular silicone oil and sterilized air after single pars plana vitrectomy for rhegmatogenous retinal detachment. 2020.
7. Kornmann HL, Gedde SJJCoio.
Glaucoma management after vitreoretinal surgeries.
2016;27(2):125.
8. Liu Z, Fu G, Liu AJE, medicine t.
The relationship between inflammatory mediator expression in the aqueous humor and secondary glaucoma incidence after silicone oil tamponade.
2017;14(6):5833-6.
