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In the article presented by Wickham and associates,1 the authors compared vitrectomy and gas for treating inferior break retinal detachments with vitrectomy, gas and scleral buckle. The study showed no significant difference in the final outcome between the two groups. While vitrectomy and gas for inferior break retinal detachments appears promising, there are several issues that we would like to raise.
Firstly, the surgery was performed by a registrar, fellow, or consultant. These surgeons may have varying degrees of experience and the inconsistency may affect the rate of successful surgical outcome. Secondly, additional tears were treated with cryotherapy or laser. As shown by Bonnet et al,2 the postoperative proliferative vitreoretinopathy (PVR) rate could be as high as 25.8% in patients treated with cryotherapy compared to 2.2% in the laser group. It is unclear what the relative distribution of patients who underwent cryotherapy in the two groups was and this may have been a confounding factor in the study. Thirdly, patients underwent an air/gas exchange with either SF6 or C3F8. As C3F8 had a much longer duration of tamponade than SF6, the use of one agent over another may have led to a difference in the success rate.
The study excluded patients with PVR grade C. However, for those with grade A or B, a scleral buckle was planned before the operation. This could lead to a selection bias where potentially more difficult cases were scheduled into the scleral buckle group. This may be a contributing factor for a higher rate of postoperative PVR (20%) and epiretinal membrane formation in this group, compared to a rate of 5–10% reported previously.3,4 The underlying vitreoretinal pathology rather than the placement of the scleral buckle may have been a major reason behind the high PVR rate noted in this group.
The authors stated that the main reasons for performing vitrectomy and gas without scleral buckle was to avoid the possible complications of scleral buckle—namely, longer operating time,5 exposure, refractive change, diplopia, and anterior segment ischaemia.6–10 Perhaps, in the interest of readers, the authors can provide us with the information if any of these complications developed during the study.
The high rate of final reattachment reported in the study is encouraging. We believe that vitrectomy and gas alone is an effective method to treat selected cases of retinal detachments with inferior retinal breaks. A controlled, randomised, prospective study, comparing the outcome in properly matched groups and with meticulous attention to surgical methods11 will help address some of the above issues and help elucidate further if the procedure without the use of scleral buckle will benefit patients with inferior break retinal detachment.
We would like to commend the authors for conducting this very nice study on an important topic that may provide a better alternative treatment. We wish that the issues that we raise will help broaden the discussion on the topic.