Encircling scleral buckling for the treatment of retinal detachment: Development in indication and outcome within the last decade

doi:10.21203/rs.3.rs-2068582/v1

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Encircling scleral buckling for the treatment of retinal detachment: Development in indication and outcome within the last decade

https://doi.org/10.21203/rs.3.rs-2068582/v1

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Background/Objectives: To evaluate the use of encircling scleral buckling for treating retinal detachment (RD) and its complications as well as success rate within the last decade.

Subjects/Methods: This retrospective observational study included 163 eyes receiving encircling scleral buckling (ESB) or ESB combined with vitrectomy (SBV) between 2009 and 2018. Main outcome measures include usage rate of ESB and SBV, indications and mean age. Furthermore, intra-/postoperative complications, intraocular tamponades as well as influences on functional outcome (BCVA) and central retinal thickness (CRT) were evaluated. For statistical analysis, patients were divided into five groups of two years each.

Results: ESB and SBV surgeries decreased from initially 32% of all RD-operations between 2009-2010 to 9.2% between 2017-2018 (p<0.001, ANOVA). Mean age at surgery differed significantly over the years from 56.9±17.1 between 2009-2010 to 37.6±28.3 between 2017-2018 (p<0.001, ANOVA). Functional outcome after a mean follow-up time of 43.1±39.5 months increased from 1.34±0.88 logMAR at baseline (BSL) to 0.99±0.87 logMAR at the last follow-up visit. Significant influencing factors on BCVA were BCVA at BSL (p<0.001), duration of RD (p=0.01) and lens status (pseudophakic > phakic > aphakic, p<0.001). Significant impacts on CRT were surgical technique (SBV > ESB, p=0.017) and macula on/off (off > on, p=0.036).

Conclusion: After an initial decrease, a rebound in ESB and SBV surgeries was noticed, with a significant reduction in mean age. Indications for surgery shifted over our observational period. No significant differences in functional outcome as well as intra- and postoperative complications were observed.

vitreoretinal surgery

retinal detachment

encircling scleral buckling

scleral buckling

vitrectomy

retina

Retinal detachment repair is a complex subject, requiring careful consideration which type of surgery to use depending on the type, count and/or location of the breaks, patients’ age, lens status as well as experience of the surgeon, among other factors. In recent years, pars plana vitrectomy has become the method of choice for retinal detachment repair in most centers worldwide.

What this study adds:

After an initial decrease, a rebound in encircling scleral buckling (ESB) and ESB combined with vitrectomy (SBV) surgeries was noticed, with a significant reduction in mean age. Indications for ESB/SBV surgery shifted over our observational period to more complicated cases. No significant differences in functional outcome as well as intra- and postoperative complications were observed. ESB/SBV still plays an important role in complicated retinal detachments and young phakic patients.

Almost a century has passed since Gonin postulated his surgical techniques for simple retinal detachment (RD) and the closure of retinal holes using electric cautery.¹ Since then, numerous advances in RD surgery have been developed, of which nowadays especially pars plana vitrectomy (PPV) and scleral buckling (SB) remain the most relevant. In 1949, Ernst Custodis was the first person to scientifically publish the use of an external buckle in a larger number of patients, deriving from evolving techniques in scleral resection.^2,3 At approximately the same time, Schepens developed an encircling tube made out of polyethylene, reporting a success-rate of 83.3% - these results are comparable to recent studies over 50 years later.⁴

PPV was developed in the 1970s by Robert Machemer.⁵ Initially intended for the repair of complex rhegmatogenous RD (RRD), over time and with the development of increasingly small instruments, PPV through transconjunctival ports started to become the standardized procedure for the treatment of primary RRD.⁶ These smaller instruments with their small incision size allow for a much lower rate of complications.⁷

A decision for the surgical technique will be made depending on the type, count and/or location of the breaks, patients’ age, lens status as well as experience of the surgeon.^8–12 PPV is the method of choice for the treatment of RRD mainly in older patients and/or patients with giant retinal tears, vitreous hemorrhage, breaks at the posterior pole or RRD associated with proliferative vitreoretinopathy (PVR). On the other hand, SB is often performed in RRD with good visibility of the fundus and breaks on the same level.¹³ Furthermore SB is indicated in young patients with phakic clear lenses, dialysis associated RD and as an adjunct to vitrectomy for RD after trauma or PVR.⁹ Intra- and postoperative complications seem to happen at a comparable rate, although they are much more variable with PPV than with SB.¹⁴ Despite various treatment schemes assisting decision-making, the final decision for the surgical technique will be made by the surgeon. This fact could affect the development of methods for the treatment of primary RRD.

To our knowledge, there is only sparse literature showing the change in proportion and complication rate of encircling scleral buckling (ESB) and ESB combined with vitrectomy (SBV) for the surgical treatment of RD over the last decade. Hence, we aimed to evaluate the development of ESB surgical technique for the treatment of RD and its complications as well as success rate within the last decade.

In this clinical study, data of consecutive patients undergoing either ESB or SBV for RD between 2009 and 2018 at the Department of Ophthalmology and Optometry, Medical University of Vienna, Austria, were retrospectively analyzed. The study was approved by the institutional review board of the Medical University of Vienna (EK948/2011) and was conducted according to the Tenets of the Declaration of Helsinki. All surgeries were performed by three experienced retinal surgeons (SS, MG, CA).

Demographic and morphological data were analyzed. Refractive error in phakic patients was assessed prior to the scleral buckling procedure. In eyes with vitreous hemorrhage and/or macula off RD, the diopters of the eye spectacle were considered. For the refractive error in pseudo- and aphakic patients, the latest available assessment before lens removal was used. Patients with a refractive error > 6 dpt were excluded from this analysis. Best corrected visual acuity (BCVA) was measured using the Snellen scale preoperatively and at the latest follow-up (LFU). Furthermore, central retinal thickness (CRT) of the study eye at the LFU available was measured on Zeiss Cirrus HD-OCT images (Cirrus; Carl Zeiss Meditec, Inc., Dublin, CA). In addition, intraocular tamponade (none, silicone oil, gas: hexafluoroethane (C2F6), octafluoropropane (C3F8) or sulfur hexafluoride (SF6)), intraoperative and postoperative complications as well as anatomical success rate were noticed.

To be able to properly evaluate the development over time, the time span of 10 years was divided into five periods of two years each (2009/2010, 2011/2012, 2013/2014, 2015/2016 and 2017/2018).

Treatment Scheme

Initially, a decision tree was created at the Department of Ophthalmology and Optometry, Medical University of Vienna in 2008 to assist surgeons in their choice of surgical technique ¹⁵. This scheme was intended for orientation at the department and had no guideline characteristics. Therefore, the surgeons were able to make their own decision for the treatment of RRD. All three surgeons agreed on the use of ESB and SBV in eyes with PVR-C especially showing signs of inferior shrinking, phakic young eyes with defects in multiple quadrants located around the equator and as a secondary treatment option with persistent PVR if vitrectomy alone was not sufficient. Still, it was the last decision of the surgeon which technique to use in the individual case.

Statistical Analysis:

Statistical analysis was performed using IBM SPSS version 26 (SPSS, Inc., Chicago, IL). Values are expressed as mean ± standard deviation. To evaluate the demographic, clinical and surgical data, Chi-Square tests, t-tests and ANOVA were computed. Pairwise post-hoc testing was performed only if a significant result was seen in the ANOVA. For epidemiological analysis, all eyes were included. For regression analysis, only patients with healthy fellow eyes were evaluated. If both eyes of a patient received surgery for RD over our study period, only the first eye was analyzed since the second eye did not have a health reference.

To assess differences in CRT between the study eye and fellow eye, a multiple regression (MR) was computed with CRT defined as the dependent outcome. As a second step, the impact of the independent variables expansion of RD, surgical technique, intraocular tamponade, epiretinal membrane (ERM) formation, lens status, macular hole, age of the patient, duration of RD, duration of surgery, primary diagnosis, follow up time and periods on CRT in the study eye were investigated. To assess the impact of clinical factors on the change of BCVA from baseline (BSL) to LFU, we calculated a MR analysis with change of BCVA (logMAR) as the dependent outcome. We defined the same variables as independent variables as for CRT, with the addition of BCVA at BSL. All independent parameters were first included in the MR and backwards elimination was performed until the final regression model was found. Non-metric variables were dummy-scaled for the MR (e.g. Fovea off: 1, Fovea on: 2). Pairwise testing for non-metric, non-binary parameters was performed if a significant result was seen in an analogous linear model. No correction for the pairwise testing was performed. A p-value of < 0.05 was considered statistically significant.

Between 2009 and 2018, 1316 eyes received surgery for RD performed by 3 experienced surgeons (SS, MG, CA), of which 7.8% (n = 102) were treated with SBV, while 4.6% (n = 61) received ESB. Hence, 163 eyes of 159 patients (56 female, 103 male; f:m = 1:1.84) with a mean age of 48.92 ± 23.13 years (ESB: 48.52 ± 22.95, SBV: 49.16 ± 23.34) were included in the study. ESB was performed in 37.4% of eyes (n = 61), while 62.6% (n = 102) were treated with SBV. Mean follow-up time was 43.1 ± 39.5 months (median = 50.5 months). 55.2% of eyes (n = 90) were myopic, 26.4% (n = 43) emmetropic and 10.4% (n = 17) hyperopic. No exact preoperative refractive data was available for 13 (8%) eyes. 40.5% of eyes (n = 66) were macula on and 59.5% of eyes (n = 97) macula off detachments. Further characteristics over the periods are illustrated in table 1.

Changes in case selection and frequency of encircling scleral buckling/vitrectomy

Indications for ESB/SBV surgery did differ significantly over the years (p = 0.003, Chi-square test). In general, indications for ESB/SBV surgery were either primary RRD (n = 71, 43.6%), re-RD (n = 58, 35.6%) or exudative/tractive RD (n = 34, 20.9%). While primary RRDs made up 62% (n = 44) of ESB/SBV-surgeries in 2009/2010, their number declined to only 30.3% (n = 10) in 2017/2018. On the other hand, tractive/exudative RDs treated with ESB/SBV increased from initially 9.9% (n = 7) in 2009/2010 to 33.3% (n = 11) of surgeries in 2017/2018, marking a shift in indications. Significant differences in indications were also found comparing ESB and SBV surgery, as significantly more re-RDs and complicated RDs were treated with SBV (Chi-square test, p = 0.003)

In 2009/2010, ESB and SBV made up a combined total of 32% of all performed RD-surgeries (n = 71), hitting a low peak in 2013/2014 with 5.2% (n = 14) and then slightly increasing again in 2017/2018 to 9.2% (n = 33; p < 0.001, ANOVA, Fig. 1). Since 2009/2010, ESB and SBV surgeries decreased significantly for all time periods (p < 0.001, post-hoc test (ANOVA), respectively). Statistically significant differences between the 5 periods concerning the age distribution were observed (p < 0.001, ANOVA; see table 1). A post-hoc comparison revealed that patients receiving ESB/SBV surgery were significantly younger in 2015/2016 and 2017/2018 compared to 2009/2010 (p < 0.001; respectively).

The rate of macula off RDs did not change significantly over the periods (p = 0.088, Chi-square test). Most patients (n = 60, 36.8%) presented with a two-quadrant RD (40.8, 25, 46.2, 39.1, 33.3% between the periods, respectively), followed closely (n = 49, 30,1%) by four-quadrant RD (25.4, 40, 38.5, 30.4, 33.3% between the periods, respectively). There was also no significant difference concerning refraction before ESB or SBV surgery (p = 0.402, Chi-square test). However, the choice of intraocular tamponades varied significantly (p < 0.001, Chi-square test, see table 2).

In general, 35% of eyes (n = 57) had a phakic clear lens, 19% (n = 31) showed signs of crystalline lens opacification, 36.8% (n = 60) were pseudophakic and 9.2% (n = 15) aphakic.

Significant differences between phakic and pseudophakic eyes concerning the type of surgery were observed (p = 0.03, Chi-square test). Out of eyes treated with ESB, 70.9% were phakic (n = 39) and 29.1% pseudophakic (n = 16); out of those treated with SBV, 52.7% were phakic (n = 49) and 47.3% pseudophakic (n = 44). The use of tamponades also differed significantly depending on the lens status (p < 0.001, Chi-square test). Details are shown in table 2.

Anatomical success rate

Overall, final anatomical success in patients receiving ESB and SBV surgery was achieved in 79.1% (n = 129) of eyes after the first surgical procedure, in 90.8% (n = 148) after one follow-up surgery, in 93.3% (n = 152) after two follow-up surgeries and in 93.9% (n = 153) after three follow-up surgeries. The primary anatomical success rate neither showed significant differences from 2009/2010 to 2017/2018 (Chi-square test, p = 0.217) nor between the type of surgery (ESB: 16.4%, n = 10; SBV: 20.6%, n = 21, Chi-square test, p = 0.551). 10.1% (n = 16) of patients were treated for RD in the fellow eye over the course of our observational period (mean time until fellow eye surgery = 14.9 ± 14.5 months, median = 12.6 months). Out of those, 4 eyes were included in our epidemiological results, while 12 eyes were treated with primary PPV for RD and therefore not included in this analysis.

Complication rate

Intraoperative complications (choroidal hemorrhage) were observed in only 1 eye. Complications in both surgery groups were as follows: cataract (28.4%, n = 48), ERM formation (24.5%, n = 40), glaucoma (6.1%, n = 10), macular edema (5.5%, n = 9), macular hole (3,7%, n = 6), presence of silicone oil in the anterior chamber (3.5%, n = 6), anisometropia > 3 dpt (1.2%, n = 2), perfluorocarbon liquid-blister formation under the retina (0.6%, n = 1), and ESB displacement (0.6%, n = 1). No significant changes over time were noticed for any postoperative complications. A subgroup analysis comparing the complication rates between SBV and ESB revealed no significant differences. The total rate of re-RD was 20.9% (n = 34). 14.7% (n = 24) of re-RDs happened due to development of PVR-C, 3.1% (n = 5) as a consequence of acute retinal necrosis (ARN), 1.8% (n = 3) due to congenital vitreoretinopathy, and 0.8% (n = 1) due to previous endophthalmitis as well as persistent hemangioma, respectively.

Central retinal thickness

Surgical technique (CRT with ESB = 286.6 ± 65.3 µm, CRT with SBV = 326.5 ± 148.7 µm, MR: p = 0.017) and expansion of RD (macula off > macula on) had statistically significant impact on CRT (CRT with macula on = 309 ± 130.8 µm, CRT with macula off = 315.5 ± 125.7 µm; MR: p = 0.036). There was a significant difference between mean CRT at LFU in the study eye (312.7 ± 127.1 µm) and fellow eye (270.9 ± 39.7 µm; p = 0.007, paired t-test). Mean change in CRT between the periods is shown in Fig. 2 (p = 0.714, ANOVA, Fig. 2).

Best Corrected Visual Acuity

Mean BCVA at BSL was 1.34 ± 0.88 logMAR, at the LFU 0.99 ± 0.87 logMAR (p < 0.001; paired t-test; mean BCVA at LFU in logMAR between the periods: p = 0.002, ANOVA, table 1). The mean BCVA change from BSL to LFU was − 0.33 ± 0.73 logMAR (mean BCVA change in logMAR between the periods: p = 0.042, ANOVA, table 1/ Fig. 3). Significant influences on BCVA were BCVA at BSL (p < 0.001, MR), duration of RD (p = 0.01, MR) and lens status (p < 0.001, MR). A post hoc comparison revealed that aphakic eyes had a significantly lower BCVA than clear phakic (p = 0.045) and pseudophakic eyes (p = 0.015).

This retrospective analysis was designed to demonstrate changes in the indications and general management of ESB surgery over a period of 10 years. Our results suggest that indications for ESB and SBV surgery did indeed shift to more complex cases than primary RRD. Mean age of patients decreased significantly in more recent years. Furthermore, we evaluatedCRT and BCVA influencing parameters in eyes with ESB/SBV and could show that CRT is significantly higher in eyes receiving ESB and SBV compared to healthy fellow eyes, as well as a mean BCVA increase of -0.33 ± 0.73 logMAR from BSL to LFU, a result comparable to recent studies.^6,16

Our results show that between 2009 and 2018, the frequency of ESB and SBV surgery declined until 2014, followed by an increase until 2018 (for details see table 1). This development in ESB and SBV has, to our knowledge, not yet been reported in recent studies, as there has generally been a shift away from ESB and SBV towards PPV, even though ESB and SBV show favourable results over PPV for certain indications in some studies.^3,13 An analysis of change comparing surgical procedures between the periods 1999–2001 and 2004–2006 revealed an increase of PPV from 30.1–78.4%.¹⁷ For this study, the surgeons had free choice over which method they wanted to use. A shift in surgical management towards PPV seems to have happened without a change in functional outcome, intra- and postoperative complications in most centers worldwide.^18,19 These results were reproduced in our study, as 62% of eyes received ESB/SBV-surgery for primary RRD in 2009/2010 and only 30.3% in 2017/2018. Since this has not yet been described in the literature, it is difficult to compare these results. We found that over the years the number of children with RD at our department increased, as can be observed when looking at the mean age over the periods. In this younger population, exotamponades are generally preferred compared to endotamponades. Patients receiving ESB/SBV surgery for primary RD from 2015 onwards were mostly children.

There is an active turn from ESB-surgery to PPV for primary RRD. Nowadays, ESB-surgery is reserved for more specific indications, as good visibility of the fundus is important and breaks should be roughly on the same level.¹³ Young phakic patients with clear lenses and patients suffering from dialysis associated RD may profit from ESB over PPV. In addition, it may be useful as an adjunct to vitrectomy for RD after trauma or PVR.⁹ ESBs provide support in areas of vitreoretinal traction away from the RD.²⁰ Intra- and postoperative complications seem to happen at a comparable rate, although they are more diverse with PPV than with ESB.^14,15 Ultimately it is the surgeons’ choice which method is most suitable to perform.^8–12 Young surgeons often shy away from ESB-surgery, as it demands experience to perform it correctly.^20,21

Regarding the demographic characteristics, approximately two thirds of patients undergoing ESB or SBV surgery in our study were male. This male dominance in patients undergoing surgery for RRD has previously been described.²² Concerning the age distribution over the 5 periods, we found that patients became significantly younger over our observational period and were also substantially younger than in most other studies.^6,23 From 2015/2016 onwards, mean age was significantly lower than from 2009–2014. In our study, we observed shifting of ESB and SBV to more complicated and carefully selected cases. Especially in young patients it is important to preserve the vitreous to prevent possible iatrogenic damage, as it is strongly adherent to the retina as well as to keep the phakic lens from cataract development.

Concerning intraocular tamponades, we observed a highly significant change over the periods, especially comparing silicone oil and gas. In 2009/2010, a higher percentage of eyes was treated with gas, its use strongly declining over our 10 years of observation (table 2). On the other hand, the use of silicone oil more than doubled from 2009/2010 to 2017/2018. This upsurge in silicone oil usage may be attributed to the shift of indications for ESB and SBV surgery to more difficult cases over the years, as silicone oil represents the main choice of intraocular tamponade in cases of complicated RD surgery.²⁴ Most eyes with clear phakic lenses received no tamponade in order to preserve the lens, whereas most pseudophakic eyes received C3F8 or silicone oil.

During the presented time period, all complicated vitreoretinal surgeries were performed by experienced surgeons, which might be the reason for the low rate of intraoperative complications both in ESB and SBV surgery. Only one eye presented with choroidal hemorrhage. In regards to postoperative complications, our results comply with other studies.¹⁶ Common complications of ESB-surgery such as inflammation or intractable diplopia due to a tightly wound scleral band were not observed in our study population. Also, no case of endophthalmitis was observed.²⁵ One eye showed signs of ESB migration followed by a subsequent removal of the ESB, with the retina still attached after removal. Ten eyes developed glaucoma after surgery, which can most likely be attributed to the intraocular tamponade such as silicone oil as is widely described in current literature.^24,26 There has been growing concern about ESBs leading to retinal ischemia by obstructing blood flow to the peripheral retina, especially if not attached correctly.^27–29 During our FUT, no obvious clinical signs of retinal ischemia were noticed.

In our study, the rate of re-RD after surgery was 20.9%. While this may seem high at first, one must take into account that we did not just look at primary RRD surgeries, but also included more complicated indications with a significantly longer FUT than most studies. While most eyes were treated for primary RD, there were other diagnoses which led to re-RD, namely patients already treated for re-RD as well as eyes after previously performed vitrectomy. The other re-RDs can be attributed to an expectedly poor outcome after primary diagnosis, such as acute retinal necrosis, trauma, congenital vitreoretinopathies, Coats disease and endophthalmitis. Nevertheless, during our observational period, a final anatomic success rate of 93.3% could be achieved. These findings, even including more complex cases, reflect previous study results.^6,30−32

We examined whether there was a difference in CRT of study and fellow eyes and potential influencing factors. The mean CRT was higher in the study-eyes undergoing SB-surgery than the fellow eyes, which is in compliance with a recent study showing increased CRT after ESB surgery.³³ A previous study looked at 130 scleral buckling surgeries and found that 6.9% of eyes developed postoperative macular edema, a result similar to our study.³⁴ Although epiretinal membranes occurred at a larger number postoperatively, they did not have a significant influence on central retinal thickness.

When looking at the functional outcome of ESB and SBV surgery, an increase in mean BCVA from BSL to LFU was recorded. Lens status turned out to be a significant influence on BCVA. Unsurprisingly, aphakic patients had a worse BCVA postoperatively compared to clear phakic and pseudophakic eyes. The larger the expansion of the RD was, the lower was the BCVA, as shown in numerous other studies.^35,36

In terms of limitations, at first the retrospective nature of the study has to be mentioned. As a consequence, the patients included were not a homogenous collective, but rather represent a real-world population receiving the surgical procedure deemed most suitable for the specific indication. As most eyes presented with macula off, OCT image acquisition was often not possible at BSL due to the lack of clear ocular media. However, our primary focus was not to compare BSL images to LFU, but rather to get a long term follow up comparison of CRT of the study eye with the adjacent fellow eye to get a better understanding of CRT changes after surgery.

In conclusion, we demonstrated a shift in indications for ESB and SBV surgery over an observational period of 10 years. After an initial decrease in the first six years, an increased number of ESB and SBV surgeries was performed from 2015 to 2018. Patients were significantly younger from 2015 to 2018 than in the periods before. No significant differences in functional outcome as well as intra- and postoperative complications were observed between the periods. Nowadays, with PPV being the first line therapy for RRD in most centers, ESB and SBV take up a niche role for patients with complex RDs and young phakic patients.

Declaration of Interest:

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. None of the authors received government or nongovernment funding.

Acknowledgements

This abstract was previously presented at the annual meeting of the Association for Research and Vision in Ophthalmology in Denver, CO on 03/May/2022 as well as the Austrian Association of Ophthalmology on 28/May/2022. We thank the team of the Vienna Clinical Trial Center (VTC) for their contribution. The authors of this study have no conflicts of interest.

Authors Contribution Statement

JI was responsible for writing the original article as well as acquiring patients data. MH was responsible for collecting patient data. KE created an initial database of all surgeries performed during the given timeframe and also collected patient data. CAF performed surgery and interpreted patient data. GSR performed statistical analysis as well as contributed to writing the article. AP as well as USE provided their input in designing the study as well as feedback on the original manuscript. MG had the initial idea for this study, performed surgery and provided his experience and knowledge for patient data interpretation. SS, as the corresponding author, was responsible for overviewing the progress of the article, interpreting patient data, providing feedback and corrections where necessary and performed surgery.

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Table 1 Demographic, clinical, and surgical characteristics over the different timeperiods and in total. Values are expressed as mean ± standard deviation. A p-value of 0.05 was considered statistically significant.

Timeperiod	2009/2010	2011/2012	2013/2014	2015/2016	2017/2018	Total	p value
Age (years)	56.9 ± 17.1	58.6 ± 15.1	47.5 ± 23.2	32.3 ± 22.9	37.6 ± 28.3	48.9 ± 23.1	< 0.001*
Duration of surgery (min)	117.18 ± 45.8	131.59 ± 32.71	141.5 ± 23.58	124.05 ± 42.91	134.03 ± 48.56	125.1 ± 43.58	0.235*
BSL BCVA (logMAR)	1.22 ± 0.77	1.47 ± 0.8	1.73 ± 0.88	1.35 ± 0.95	1.38 ± 1.08	1.34 ± 0.88	0.167*
LFU BCVA (logMAR)	0.65 ± 0.75	1.13 ± 0.94	1.97 ± 1.03	0.75 ± 0.68	1 ± 0.86	0.99 ± 0.87	0.002*
BCVA change (logMAR)	-0.48 ± 0.63	-0.26 ± 0.53	0.21 ± 0.80	-0.19 ± 0.89	-0.37 ± 0.81	-0.33 ± 0.73	0.042*
	All	All	All	All	All	All
	ESB \| SBV	ESB \| SBV	ESB \| SBV	ESB \| SBV	ESB \| SBV	ESB \| SBV
Nr of surgeries	71	22	1 4	23	33	163	< 0.001**
Nr of surgeries	39 \| 32	1 \| 21	3 \| 11	7 \| 16	11 \| 22	61 \| 102
Gender							0.052**
Male	49	15	7	9	24	104
Male	26 \| 23	1 \| 14	1 \| 6	2 \| 7	7 \| 17	37 \| 67
Female	22	7	7	14	9	59
Female	13 \| 9	0 \| 7	2 \| 5	5 \| 9	4 \| 5	24 \| 35
RD-size (in quadrants)							0.513**
0	0	1	0	0	0	1
0	0 \| 0	1 \| 0	0 \| 0	0 \| 0	0 \| 0	1 \| 0
1	14	4	1	2	3	24
1	10 \| 4	0 \| 4	0 \| 1	0 \| 2	1 \| 2	11 \| 13
2	29	5	6	9	11	60
2	17 \| 12	0 \| 5	1 \| 5	3 \| 6	3 \| 8	24 \| 36
3	10	2	1	5	8	26
3	5 \| 5	0 \| 2	0 \| 1	1 \| 4	3 \| 5	9 \| 17
4	18	8	5	7	11	49
4	7 \| 11	0 \| 8	2 \| 3	3 \| 4	4 \| 7	16 \| 33
Refraction							0.402**
Hypermetropia	7	1	2	4	3	17
Hypermetropia	3 \| 4	0 \| 1	0 \| 2	1 \| 3	0 \| 3	4 \| 13
Emmetropia	15	8	2	8	10	43
Emmetropia	10 \| 5	1 \| 7	0\| 2	0 \| 8	3 \| 7	14 \| 29
Myopia	48	12	4	9	17	90
Myopia	26 \| 22	0 \| 12	0\| 4	6 \| 3	7 \| 10	39 \| 51

BCVA = best corrected visual acuity, BSL = baseline, CRT = central retinal thickness, LFU = last follow up, RD = retinal detachment; Statistical analysis: *ANOVA, **Chi-square test

Table 2 Use of intraocular tamponades with different lens status and for all eyes included in this study. A p-value of 0.05 was considered statistically significant. *Gas = C3F8, SF6, C2F6, Air; **also including aphakic eyes; ***statistical analysis with Chi-square test

IO Tamponade	2009/2010	2011/2012	2013/2014	2015/2016	2017/2018	Total	p value
Phakic							0.009***
None	16	1	1	7	10	35
Silicone Oil	7	6	6	9	7	35
Gas*	12	2	0	3	1	18
Pseudophakic							< 0.001***
None	7	0	0	0	0	7
Silicone Oil	5	6	2	4	10	27
Gas*	20	2	0	0	3	25
All**							< 0.001***
None	24	2	3	7	11	47
Silicone Oil	13	14	11	13	18	69
Gas*	34	6	14	3	4	61

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Encircling scleral buckling for the treatment of retinal detachment: Development in indication and outcome within the last decade

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Changes in case selection and frequency of encircling scleral buckling/vitrectomy

Anatomical success rate

Complication rate

Central retinal thickness

Best Corrected Visual Acuity

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