Scleral buckle, vitrectomy, or combined surgery for inferior break retinal detachment: Systematic review and meta-analysis

Topic: To compare outcomes of scleral buckle (SB), pars plana vitrectomy (PPV), and combined PPV-SB to treat rhegmatogenous retinal detachments with inferior retinal breaks (IRB-RRD). Clinical relevance: IRB-RRD are not uncommon; their management is challenging with higher risk of failure. There is no consensus about their treatment, specifically whether SB, PPV or PPV-SB should be performed. Methods: Systematic review and meta-analysis. Randomised controlled trials (RCT), case-control, and prospective/retrospective series (if n >50) in English were eligible. Medline, Embase and Cochrane databases were searched up to 23rd January 2023. Standard systematic review methods were followed. The following outcomes at 3 (± 1) and 12 (± 3) months were evaluated: number of eyes with retinal re-attachment following one and more than one surgery; change in best-corrected visual acuity (BCVA) from preoperative to postoperative levels and number of eyes with improvement of >10 and >15 ETDRS letters following surgery. Authors of eligible studies were asked for individual participant data (IPD) and IPD meta-analysis undertaken. Risk of bias was assessed using NIH study quality assessment tools. This study was registered prospectively in PROSPERO (CRD42019145626). Results: A total 542 studies were identified; 15 were eligible and included, 60% were retrospective. IPD was obtained from 8 studies (1017 eyes). Given that only 26 patients had received SB alone, these data were not considered in the analysis. There was no evidence for differences between treatment groups (PPV versus PPV-SB) in the probability of having a flat retina at 3 or 12 months postoperatively after one (p= 0.067, Odds Ratio [OR] 0.47; p=0.408, OR 2.55, respectively) or more than one (OR 0.54, p = 0.21; p=0.926, OR 0.89, respectively) surgery. PPV-SB showed less improvement in vision post-operatively at 3 months (estimate 0.18; 95% CI 0.01, 0.35; p = 0.044) but this difference was no longer observed at 12 months (estimate -0.07; 95% CI -0.27, 0.13; p= 0.479). Conclusion: Available evidence suggests a lack of benefit of adding SB to PPV to treat IRB-RRD. Evidence, however, comes mainly from retrospective series and, thus, despite the large number of eyes included, should be interpreted with caution. Further research is needed.