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Rhegmatogenous retinal detachment (RRD) is an important cause of vision loss worldwide, with an annual incidence rate of 6.3 to 18.9 per 100,000 individuals.1–3 The main treatment modality for RRD is surgical reattachment of the retina, which includes pneumatic retinopexy (PR), scleral buckling (SB), and vitrectomy. Generally, vitrectomy is indicated for relatively complicated RRD.4 However, vitrectomy may be more frequently associated with cataract aggravation, secondary glaucoma, and a high economic burden to poor patients in developing countries.5–7 PR has long been used for the management of RRD because it is convenient and less invasive.8–11 SB cures RRD by releasing vitreous traction, closing the retinal breaks, and bringing the retina and retinal pigment epithelium (RPE) closer to each other.12 Both PR and SB preserve the vitreous. However, they are usually indicated for relatively simple RRD. Prior studies have indicated that low intraocular pressure (IOP), persistent intraoperative detachment at the buckle, macular-off status, and posterior retinal breaks are risk factors for surgical failure of SB.13–15 Meanwhile, inferior breaks and visible vitreous traction on a tear often predict failure of PR.16,17 Nonetheless, PR and SB can complement each other. Early in 1985, Gilbert and McLeod18 and Stanford and Chignell19 introduced a technique involving sequential subretinal fluid (SRF) drainage (D), intravitreal injection of air (A), trans-scleral cryopexy (C), and episcleral explant (E) (DACE) for selected patients with bullous retinal detachment (RD). The primary operation success rates were 90%18 and 96%,19 respectively. However, after including more complicated cases (e.g., RRD with unseen retinal breaks, macular holes [MHs], or some degree of proliferative vitreoretinopathy [PVR]), the single-operation success rate decreased to 67%.20 Even after reoperation, the reattachment rate was only 81%.20 In a subsequent study, Cheng et al.21 performed short-term external SB combined with PR in patients with RRD with inferior breaks and reported a single-operation reattachment rate of 87.9%. Consistent with our clinical experience, a single PR with external drainage of SRF rarely achieves complete retinal reattachment in relatively complicated RRD because of the deep SRF, static vitreoretinal tractions on a tear, and deep locations of retinal breaks. The use of a small gas bubble in prior studies was largely ineffective for complete release of the vitreoretinal traction. In the past few years, maximal PR has been developed in our practice. Maximal PR involves injection of an adequately large non-expansile gas bubble into the vitreous to achieve thorough release of the vitreoretinal traction. We have performed maximal PR and SRF drainage combined with SB for treatment of relatively complicated RRD, such as those involving tractional tears, vitreous hemorrhage, unseen retinal breaks, and posterior holes (including MHs) with combined peripheral retinal breaks, and favorable results were achieved. The purpose of the present study was to introduce and evaluate the efficacy of maximal PR and SRF drainage together with SB for the management of relatively complicated RRD.

OBJECTIVES: To evaluate the efficacy of treatments for aqueous misdirection syndrome and explore possible risk factors influencing prognosis. METHODS: Data including demographics, initial clinical characteristics and ocular outcomes at follow-up were collected for patients treated for aqueous misdirection syndrome. Main outcome measures were: best-corrected visual acuity (BCVA); intraocular pressure (IOP); number of antiglaucoma medications; recurrence; complications. RESULTS: Data were available for 50 patients (57 eyes). Final mean BCVA improved significantly and correlated with baseline BCVA (mean follow-up, 34.47 ± 28.65 months). Final mean IOP and mean number of antiglaucoma medications were significantly reduced. Treatment failure rates were higher in patients with significantly higher IOP at baseline and/or shorter axial length. Following pars plana vitrectomy (PPV), recurrence occurred in two of 10 pseudophakic and one of 40 phakic eyes; complications were observed in 12/50 eyes (choroidal detachment, corneal decompensation, retinal detachment, vitreous haemorrhage, hyphaema). CONCLUSIONS: PPV and laser treatments, augmented by pharmacotherapy, were effective in treating aqueous misdirection syndrome. Surgical intervention should be undertaken early in eyes with higher baseline IOP and/or shorter axial length. Total vitrectomy— zonulectomy—iridectomy is a potential approach for recalcitrant cases.