Risk Factors for Iatrogenic Retinal Breaks in Eyes Requiring Surgical Induction of Posterior Vitreous Detachment

Risk Factors for Iatrogenic Retinal Breaks in Eyes Requiring Surgical Induction of Posterior Vitreous Detachment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Risk Factors for Iatrogenic Retinal Breaks in Eyes Requiring Surgical Induction of Posterior Vitreous Detachment Jai Paris, Carmelo Macri, Surbhi Agrawal, Stewart Lake, WengOnn Chan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6223838/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To determine risk factors for retinal breaks (RB) during the surgical induction of posterior vitreous detachment (IPVD). Methods: We retrospectively reviewed electronic records for all adult patients undergoing 25-G or 27-G vitrectomy surgery between November 2019 and January 2024 requiring intraoperative IPVD. We excluded eyes with pre-existing PVD, panretinal photocoagulation, trauma, or missing information. The outcome measure was non-sclerotomy-related iatrogenic RB. We assessed the effect of age, gauge size (25-G vs 27-G), surgical indication (epiretinal membrane [ERM] vs macular hole[MH]/vitreomacular traction syndrome[VMTS] vs Other), lens status (Phakic vs Aphakic/Pseudophakic) and surgeon (Consultant vs Fellow) on the odds of RB. Results: Among 253 eyes included in our study, 17% experienced a RB during IPVD. Breaks were predominantly located in the inferior retina (58%). Multivariable analysis revealed gauge size significantly impacted RB rate (27G OR 0.14, 95%CI 0.05-0.40, p = 0.0003). Other factors including age (OR 0.98, 95%CI 0.96-1, p = 0.069), lens status (Phakic OR 0.47, 95%CI 0.21-1.1, p = 0.068), surgeon grade (Fellow OR 2.5 95%CI 0.52-12, p = 0.25) and surgical indication (MH OR 0.70 95%CI 0.30-1.6, p = 0.40) were not significantly associated with odds of RB. Conclusions: There is a high rate of iatrogenic RB in eyes requiring IPVD. Smaller instrument gauge size reduced the odds of RB. Neither age, surgical indication nor lens status were associated with odds of RB. Health sciences/Health care/Therapeutics/Surgery Health sciences/Diseases/Eye diseases/Vitreous detachment Posterior Vitreous Detachment Retinal Break Vitrectomy Surgical Technique Retinal Detachment Risk Factors Synopsis Induction of posterior vitreous detachment is a risk factor for retinal breaks in eyes undergoing vitrectomy. Larger gauge surgeries are associated with a higher rate of retinal breaks. Surgical indication and age have no effect. What is already known on this topic? Surgical induction of posterior vitreous detachment (IPVD) is a risk factor for retinal breaks in eyes undergoing vitrectomy. However, little is known regarding the risk factors for retinal breaks within eyes requiring induction of PVD. What this study adds? Smaller gauge surgeries (27-G) are associated with a lower rate of retinal breaks in eyes requiring IPVD. Other factors including surgical indication, age and lens status have no impact on the rate of retinal breaks. How might this study affect research, practice or policy? Our study helps to identify patients who are at greater risk for developing retinal breaks during IPVD when undergoing vitrectomy. INTRODUCTION Induction of posterior vitreous detachment (IPVD) is a risk factor for retinal breaks (RB) during pars plana vitrectomy (PPV) 1 – 5 . Reported RB rates during IPVD range from 2.8–32.3%, which is higher compared to break rates of 0.6–3.1% observed across all vitrectomy procedures 1 , 2 . Furthermore, the presence of an existing PVD has been shown to lower the rate of RB during PPV across all gauge sizes and surgical indications including macular hole (MH), epiretinal membrane (ERM) and tractional retinal detachment (RD) 1 , 6 . Some evidence also suggests that IPVD may increase the rate of postoperative rhegmatogenous RD, and this is thought to be due to missed intraoperative breaks 2 . Despite well-established literature for IPVD as a risk factor for RB during PPV, few studies explore factors that may influence this risk. There is conflicting evidence regarding the impact of surgical indication on the risk of RB. Some studies suggest ERM surgery confers a higher RB rate 1 , 2 . There has been significant interest regarding differences in the effect of cannula size on RB rates in eyes undergoing vitrectomy. Some studies show higher break rates in larger gauge, higher vacuum setting surgeries, however, most show no impact from gauge size 4 , 7 – 9 . Few other factors that might affect RB rate in IPVD have been explored in the literature. Younger age has been shown to increase RB rate in eyes with IPVD 10 . Prior studies often include all vitrectomies, the majority of which do not require IPVD, making the evidence within IPVD subgroups scarce. The evidence regarding the significance of surgical indication and gauge size is supported by few relatively small-scale studies. We sought to identify risk factors for retinal breaks from a retrospective cohort of vitrectomies requiring IPVD, and to evaluate the nature and characteristics of break location in these eyes. METHODS We reviewed the electronic medical records of all adult patients who underwent vitrectomy surgery between November 2019 and January 2024 at the Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, South Australia. Ethics committee approval was obtained from the Central Adelaide Local Health Network Human Research Ethics Committee (reference number 19813) and the study adhered to the tenets of the Declaration of Helsinki. We included all eyes which underwent pars plana vitrectomy and required intraoperative induction of posterior vitreous membrane detachment, with follow up of at least 1 month. We excluded eyes with pre-existing complete or partial PVD, those without documentation of induction techniques or intraoperative findings, eyes with previous penetrating or blunt trauma, and eyes with previous panretinal photocoagulation. All patients underwent thorough preoperative assessment including an examination for best corrected visual acuity (BCVA), slit lamp examination and dilated fundus examination. Three port PPV was performed using a 25-, or 27-G vitrectomy system (Constellation Vision System, Alcon). Sclerotomies were placed 4 mm posterior to the limbus in phakic eyes and 3.5 mm in pseudophakic eyes. An infusion cannula was positioned in the inferotemporal quadrant, and supertemporal and superonasal sclerotomies were made near the 10- and 2-o’clock meridians. Absence of PVD was confirmed intraoperatively with intravitreal triamcinolone acetonide (IVTA). Induction was then performed by engagement of the attached posterior hyaloid with a 25-G or 27-G angulated dissecting needle in the area adjacent to the optic disc and elevating this in a posteroanterior direction extending at least 3-disc diameters from the margin of the optic disc. The PVD was then extended using the vitrectomy probe in a cutting mode off and a vacuum rate of 650 mmHg. Every procedure was then performed using a fixed cut rate of 5000 cuts per minute (cpm). The vacuum was set between 500 and 650 mmHg during the core vitrectomy and between 20 and 300 mmHg during peripheral vitreous removal. Surgical procedures varied after vitreous removal, depending on the pathology. The primary outcome was the occurrence of one or more non-sclerotomy-related RB. RBs were diagnosed by a careful 360-degree peripheral search of the retina using the Resight viewing system coupled with a Lumera 700 microscope. Definite RB had characteristics including an elevated retinal flap with a discrete edge. Breaks without a definite flap, edge or retinal defect observed during scleral indentation were excluded from the present study. Sclerotomy-related retinal breaks were defined as breaks occurring intraoperatively that were located near 1 of the 3 sclerotomies (within 1 hour either side of the sclerotomy site) and were recorded but excluded from the main analysis. We included any breaks identified up to 1 month following surgery that fit these criteria. All iatrogenic breaks were treated with laser photocoagulation. If breaks were round or had significant underlying pigment surrounding them, they were categorised as pre-existing and excluded from the study. Data collected included demographic, clinical, surgical and post-operative findings. Patient demographics included age and sex, ocular history, prior surgical history in subject eye, history of retinal breaks or detachment, and history of diabetes with proliferative diabetic retinopathy or tractional retinal detachment. Clinical factors included laterality, phakic status, intraocular pressure (IOP), BCVA (Snellen in metres). Surgical factors included the surgery indication, surgeon seniority/grade, instrument gauge size, retinal breaks, if encountered, including their location and whether they were sclerotomy-related or breaks elsewhere. Continuous variables such as age were described using mean and standard deviation (SD) or median and interquartile range (IQR). Categorical variables such as gender, surgical indication, instrument gauge size, and surgeon grade, were summarized using frequencies and percentages. Modified generalized estimating equations logistic regression (to account for inter-eye correlation) was used to explore the association of exposures with odds of RB. Exposure variables were adjusted for the precision variable age, identified a priori from literature as a previously known risk factor and was the minimally sufficient adjustment set for all exposure of interest after the construction of directed acyclic graphs to map potential variable relationships (Supplement Fig. 1) 10 . We assessed the direct effect of age, gauge size (25-G vs 27-G), surgical indication (MH/VMTS vs ERM vs VH vs Other) and phakic status (Phakic vs Aphakic/Pseudophakic) on odds of RB, adjusted for age. Data reduction of the surgical indication variable was performed by combining VMTS and MH, and with phakic status by combining aphakia and pseudophakia. Results were reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). All statistical analyses were performed using the statistical programming language R (packages geessbin v0.1.2, glmtoolbox v0.1.11) 11 – 13 , and a p-value < 0.05 was considered statistically significant. P values were not adjusted for multiple testing due to the study's exploratory nature. RESULTS We included 253 eyes of 244 patients in the study cohort (Table 1 ). The cohort included 123 females (50%) and 121 males (50%). The median age was 69 (Range 18–94, IQR 61–77). There were 204 phakic eyes (81%), 46 pseudophakic eyes (18%), and 3 aphakic eyes (1%). There were 2 eyes with other previous intraocular surgery excluding phacoemulsification and intraocular lens implant, which included 1 case of trabeculectomy and 1 case of extracapsular lens extraction following traumatic cataract. The median preoperative BCVA was 0.70 (IQR 0.5–2.00) logMAR, i.e. 6/30 (IQR (6/19–6/600). Table 1 Clinical and surgical characteristics of included eyes Characteristic No RB, N = 210 RB, N = 43 Laterality Left 109 (52%) 22 (51%) Right 101 (48%) 21 (49%) Prior Intraocular Surgery (excluding cataract) No 208 (99%) 43 (100%) Yes 2 (1%) 0 (0%) Phakic Status Aphakic 2 (1%) 1 (2%) Phakic 173 (82%) 31 (72%) Pseudophakic 35 (17%) 11 (26%) BCVA (logMAR) 0.70 (0.50, 1.38) 0.90 (0.55, 2.00) Surgical Indication ERM 55 (26%) 12 (28%) MH/VMTS 102 (49%) 16 (37%) Other 53 (25%) 15 (35%) Surgeon Grade Consultant 16 (8%) 1 (3%) Fellow 194 (92%) 42 (98%) Gauge Size 25G 131 (62%) 40 (93%) 27G 79 (38%) 3 (7%) Previous RB No 207 (99%) 43 (100%) Yes 3 (1%) 0 (0%) BCVA: best corrected visual acuity. RB = retinal break Vitrectomies were performed either by a fellow retinal surgeon in 236 (93%) of cases, or a consultant retinal surgeon in 17 (7%) cases. The indication for surgery was MH in 44%, ERM in 26%, VH in 13%, RD or TRD in 7%, dropped or subluxed IOL/lens in 6%, VMTS in 2%, symptomatic vitreous opacity surgery in 1 (0.5%), and diagnostic vitrectomy in 1 eye (0.5%). The cannulation gauge used was 25-G in 68%, 27-G PPV in 32%. In total there were 65 peripheral RB that occurred in 43 (17%) eyes during induction of PVD (Table 2 ). All breaks occurred intraoperatively, none were detected in the postoperative follow up. Of the 65 breaks, 16 (25%) were described as inferior, 12 (18%) were inferonasal, 10 (15%) were inferotemporal, 10 (15%) were superotemporal, 4 (6%) were nasal, 4 (6%) were superonasal, 3 (5%) were superior, 2 (3%) were temporal, 1 (2%) was peripheral, and 3 (5%) were not reported. There were 3 cases of sclerotomy-related RBs which occurred in three eyes (1.2%). Two of these were described as superotemporal, and one was superonasal. Of the eyes that experienced peripheral RB, 40/43 (93%) had 25-G surgery and 3/43 (7%) had 27-G surgery. The RB rate for 25-G and 27-G cannulation systems was 58/171 (34%) and 7/82 (8.5%), respectively. Most RB occurred in phakic eyes (72%) of cases. The presence of RB by surgical indication was 15/112 (13%) for MH, 12/67 (18%) for ERM, 7/33 (21%) for VH, 3/14 (20%) for RD, 2/3 (67%) for dropped nucleus with retained lens matter, 2/3 (67%) for TRD, 1/6 (17%) for VMTS and 1/4 (25%) for subluxed IOL. Increasing age was not associated with a reduced odds of RB (OR 0.98, p = 0.069, Table 2 ). Gauge size of 27-G compared to 25-G was associated with reduced odds of RB in unadjusted and adjusted analyses (Adjusted OR 0.14, p = 0.0003). Neither lens status, surgical indication, nor surgeon grade was associated with odds of RB (Table 2 ). Table 2 Multivariable generalised estimating equations logistic regression estimating the direct effect of hypothesised exposures on the odds of RB during IPVD Factor Unadjusted OR (95% CI) p value Adjusted OR (95% CI) p value Age 0.98 (0.96–1) 0.069 Gauge Size 25G Reference Reference 27G 0.14 (0.05–0.42) 0.00043 0.14 (0.05–0.40) 0.0003 Surgical Indication ERM Reference Reference MH/VMTS 0.72 (0.31–1.6) 0.43 0.70 (0.30–1.6) 0.40 Other 1.3 (0.55-3.0) 0.56 1.1 (0.44–2.6) 0.89 Lens Status Aphakic/Pseudophakic Reference Reference Phakic 0.55 (0.25–1.2) 0.12 0.47 (0.21–1.1) 0.068 Surgeon Grade Consultant Reference Reference Fellow 2.4 (0.52–11.2) 0.26 2.5 (0.52-12) 0.25 OR: Odds ratio. CI: confidence interval. G: gauge. ERM: epiretinal membrane. MH: macular hole. VMTS: vitreomacular traction syndrome. IPVD: Induction of posterior vitreous detachment. Adjusted models are adjusted for age (as a linear variable). DISCUSSION IPVD is a known risk factor for RB during PPV 1 , 4 , 9 . The rate of IPVD-associated RB in our cohort of eyes was 17%, with 58% of these breaks occurring in the inferior retina. The frequency of RB in our eyes was in keeping with past evidence in similar patient populations of 9.02–32.1% 1,7,10 . We found that cannulation gauge size significantly impacted the rate of RB. Other demographic, patient and procedural factors including age, lens status, surgical indication and surgeon grade did not impact the odds of RB. There is conflicting evidence in literature regarding the impact of cannulation size on the rate of RB during IPVD. Most studies have demonstrated no effect of gauge size on RB rates in IPVD. Hikichi et al. performed a single surgeon retrospective review in a series of 183 eyes undergoing either MH or ERM surgery and found equal rates of RB between 20-G and 23-G surgery (20/122 (16%) vs. 10/61 (16%)) 14 . Sandali et al. reported comparable rates of RB across 553 eyes undergoing ERM surgery requiring IPVD using either 20-G, 23-G or 25-G cannulation, however no statistical analysis of the IPVD subgroup was performed (20-G 12.34% vs. 23-G 13.9% vs. 25-G 5.3%) 9 . The findings of these studies are limited by the small number of eyes requiring IPVD, and lack of an IPVD subgroup analysis. In contrast, Nakano et al. found that larger 20-G surgery experienced a higher RB rate compared to 23-G. The authors compared the RB rate in a series of 225 eyes requiring ERM surgery and 103 requiring MH surgery undergoing either 20-G or 23-G cannulation technique 7 . Vitreous cut rate was fixed at 2000 cpm with maximum aspiration pressure up to 500 mmHg for both 20-G and 23-G when inducing PVD. In eyes requiring IPVD, the incidence of iatrogenic RB was 15.8% in the 20-G group and 3.1% in the 23-G group (p = 0.0234). This finding may be limited by no distinction made between sclerotomy related breaks and breaks elsewhere. Our results demonstrate a significant impact of gauge size on RB rate, with eyes undergoing 27-G surgery having a significantly lower RB rate than those undergoing 25-G. Gauge size may have an effect through various mechanisms. It is thought that sclerotomy related breaks are due to incarceration of vitreous gel around sclerotomy sites, increasing retinal traction 7 , 15 . Iatrogenic non-entry site peripheral breaks on the other hand, are generally regarded to be secondary to the creation and extension of PVD intraoperatively and their pathogenesis is incompletely understood. The higher RB rate in 25-G surgery has previously been explained by the relatively higher vacuum settings of larger gauge surgeries, which can increase retinal traction and the propensity for RB development. However, in our series of eyes vacuum settings for both 25-G and 27-G surgery was set at 650 mmHg. Possibly the reduced cut diameter and lower duty cycle in 27-G surgery may contribute to improved fluid dynamics. Previous studies have demonstrated lower IOP fluctuations in 27-G vitrectomy compared to 25-G, regardless of the aspiration system used 16 . The higher flow limitations of cutter gauge size, port size and duty cycle may be an advantage with smaller gauge surgeries, whereby there is reduced average vitreous fibre travel between cuts, limiting the traction exerted on the retina 17 , 18 . The increase in fluid turbulence in 25-G may also affect retinal stability and increase the risk of RB 18 . Additionally, 25-G instruments have higher rigidity compared to 27-G, which may increase retinal manipulation especially in the peripheries where instrument flexibility is required 19 . Previous studies have demonstrated higher RB rates in younger patients undergoing IPVD, despite finding no association in our results 10 . Rahman et al. investigated a series of 137 patients undergoing IPVD with an age range of 32–94 years (mean 69.9), and revealed each 1-year increase in age was associated with 4.1% decreased odds of a RB (OR 0.959, p = 0.028) 10 . Additionally, they found that eyes with an adherent posterior hyaloid, defined as requiring membrane blue with targeted suction, were 3.8 times more likely to experience a RB. They did not investigate the association of age and likelihood of an adherent PHF, however this association has been well-established in other studies 20 , 21 . Ageing has been associated with partial detachment of PVD, which may lower the suction requirements during IPVD 22 . However, in our series of eyes we found that increasing age was not statistically associated with a reduction in the odds of experiencing a RB during IPVD (OR 0.98, p = 0.069). Despite an age range of 18–94 years, the older age skew within our study may limit the ability to properly examine the effect of age on RB rate. We found surgical indication was not associated with an increased odds of RBs, across a wide range of conditions requiring PPV, consistent with existing literature. Chung et al. found no difference in RB rate between eyes undergoing IPVD for ERM or MH surgery (32.1% (9/28) vs. 12.7% (19/105), p = 0.0563, respectively) 1 . Rahman et al. also revealed no association between diagnosis and increased RB rate across 137 eyes undergoing vitrectomy 10 . Other studies have shown mixed findings. Nakano et al. demonstrated a higher rate of RB in 84 eyes undergoing MH surgery compared to 38 eyes undergoing ERM (13% vs. 0%), whilst Mura et al. reported ERM may have the highest RB rate across a range of indications (4.2%, 8/189 compared to 1.9%, 2/106 VMTS in the next highest category) 2 , 7 . However, these studies do not include an IPVD subgroup analysis. We found a high proportion of peripheral RB experienced during IPVD were in the inferior retinal field. Of the 65 breaks, 58% (38/65) of breaks were in the inferior retina, compared to only 26.2% (17/65) in the superior retina. Previous studies have reported similar findings. Sandali et al. revealed within the subgroup of eyes requiring IPVD, there was a higher portion of RB that occurred in the inferior retina compared to superior retina, irrespective of gauge size and indication (81.2% vs. 19.0%) 9 . Hikichi et al. also found a significantly higher number of inferior quadrant breaks compared to superior quadrant breaks in eyes requiring IPVD undergoing 23-G surgery (68% vs. 32%, p = 0.014) 14 . The proposed mechanism is the physiological direction of PVD. Naturally occurring PVD begins superiorly and extends inferiorly, often resulting in incomplete or partial vitreo-retinal dehiscence in inferior quadrants 14 . Schneider et al. have suggested that as the vitreous undergoes physiological liquefaction and begins detaching, collagen fibrils aggregate into parallel bundles that form thicker adhesions, preventing a complete PVD inferiorly 23 . The higher degree of inferior retinal traction may explain the high inferior RB rate seen in our series of eyes. However, given the exclusion of sclerotomy-related breaks, the greater arc angle inferonasally could introduce a selection bias in the distribution of RBs. Despite this, sclerotomy-related breaks were only experienced in 3 eyes (1.2%), which is in keeping with previous evidence 2 , 24 . A strength of our study is the inclusion of only eyes requiring IPVD, which have been included only as a subgroup analyses in past studies. The implications of this research could improve preoperative risk counselling and may influence the surgical approach to eyes requiring IPVD. Our findings are limited by the retrospective nature of the study. CONCLUSION This retrospective study revealed a high rate of RB breaks in eyes undergoing PPV which require IPVD (17%). We found that 25 G compared to 27 G surgery increased the odds of experiencing a RB during IPVD. Other factors including age, lens status, surgical indication and grade of surgeon did not impact the odds of RB. The proportion of breaks located inferiorly was high (58%). Our results add further evidence regarding risk factors for RB during IPVD. Declarations Acknowledgements : Royal Adelaide Hospital Retina Research Group Weng Onn Chan (MB ChB MPhil FRANZCO), Shane Durkin (MBBS(Hons), MPHC, MMed(OphthSc), FRANZCO), Jagjit Gilhotra (MBBS, FRANZCO), David Sia (MB ChB FRANZCO), Carmelo Macri (MBBS, MPhil) Funding: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Competing Interests: The authors declare no conflict of interest or competing interests. Authorship contribution Statement: Jai Paris – Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data collection & curation, Visualisation Carmelo Macri – Writing – review & editing, Supervision, Methodology, Investigation, Formal analysis, Data collection & curation, Visualisation Surbhi Agrawal – Writing – review & editing, Supervision, Formal analysis Stewart Lake – Writing – review & editing, Supervision Weng Onn Chan – Writing - review & editing, Supervision, Formal analysis, Conceptualisation References Chung SE, Kim KH, Kang SW. Retinal breaks associated with the induction of posterior vitreous detachment. Am J Ophthalmol . Jun 2009;147(6):1012-6. doi:10.1016/j.ajo.2009.01.013 Mura M, Barca F, Dell'Omo R, Nasini F, Peiretti E. Iatrogenic retinal breaks in ultrahigh-speed 25-gauge vitrectomy: a prospective study of elective cases. 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Clin Ophthalmol . 2011;5:1151-65. doi:10.2147/OPTH.S14840 Tarantola RM, Tsui JY, Graff JM, et al. Intraoperative sclerotomy-related retinal breaks during 23-gauge pars plana vitrectomy. Retina . Jan 2013;33(1):136-42. doi:10.1097/IAE.0b013e31825e1d62 Additional Declarations There is no conflict of interest Supplementary Files Figure1.docx Supplement Figure 1 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6223838","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":451892707,"identity":"34c2cb03-8ab1-4d54-81aa-2bc0c384fa74","order_by":0,"name":"Jai Paris","email":"data:image/png;base64,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","orcid":"","institution":"University of Adelaide","correspondingAuthor":true,"prefix":"","firstName":"Jai","middleName":"","lastName":"Paris","suffix":""},{"id":451892708,"identity":"4c4a7ce6-ef0a-4c0b-be05-9fcce7a8701e","order_by":1,"name":"Carmelo Macri","email":"","orcid":"https://orcid.org/0000-0002-1110-3780","institution":"The University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Carmelo","middleName":"","lastName":"Macri","suffix":""},{"id":451892709,"identity":"401aa01d-9132-4f99-adc1-306bc7635342","order_by":2,"name":"Surbhi Agrawal","email":"","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":false,"prefix":"","firstName":"Surbhi","middleName":"","lastName":"Agrawal","suffix":""},{"id":451892710,"identity":"1c21ba6d-c591-42fe-88cd-12fdfaae22b7","order_by":3,"name":"Stewart Lake","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Stewart","middleName":"","lastName":"Lake","suffix":""},{"id":451892711,"identity":"49aedda8-0971-47d6-83bd-f7a66fb7c220","order_by":4,"name":"WengOnn Chan","email":"","orcid":"","institution":"South Australian Institute of Ophthalmology","correspondingAuthor":false,"prefix":"","firstName":"WengOnn","middleName":"","lastName":"Chan","suffix":""}],"badges":[],"createdAt":"2025-03-14 05:55:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6223838/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6223838/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90155148,"identity":"6773a638-f70d-4db2-99bf-de13ee83d1a3","added_by":"auto","created_at":"2025-08-29 08:04:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":563880,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6223838/v1/dc723dbd-8213-44b3-8900-9eaf5cba844d.pdf"},{"id":82246758,"identity":"ca3be1ec-6e9d-42ae-96fb-70a494eb330e","added_by":"auto","created_at":"2025-05-08 09:16:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":242506,"visible":true,"origin":"","legend":"\u003cp\u003eSupplement Figure 1\u003c/p\u003e","description":"","filename":"Figure1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6223838/v1/633d55e2a08295614b66f91c.docx"}],"financialInterests":"There is no conflict of interest","formattedTitle":"Risk Factors for Iatrogenic Retinal Breaks in Eyes Requiring Surgical Induction of Posterior Vitreous Detachment","fulltext":[{"header":"Synopsis","content":"\u003cp\u003eInduction of posterior vitreous detachment is a risk factor for retinal breaks in eyes undergoing vitrectomy. Larger gauge surgeries are associated with a higher rate of retinal breaks. Surgical indication and age have no effect.\u003c/p\u003e"},{"header":"What is already known on this topic? ","content":"\u003cp\u003eSurgical induction of posterior vitreous detachment (IPVD) is a risk factor for retinal breaks in eyes undergoing vitrectomy. However, little is known regarding the risk factors for retinal breaks within eyes requiring induction of PVD. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSmaller gauge surgeries (27-G) are associated with a lower rate of retinal breaks in eyes requiring IPVD. Other factors including surgical indication, age and lens status have no impact on the rate of retinal breaks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHow might this study affect research, practice or policy?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study helps to identify patients who are at greater risk for developing retinal breaks during IPVD when undergoing vitrectomy.\u0026nbsp;\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eInduction of posterior vitreous detachment (IPVD) is a risk factor for retinal breaks (RB) during pars plana vitrectomy (PPV)\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Reported RB rates during IPVD range from 2.8\u0026ndash;32.3%, which is higher compared to break rates of 0.6\u0026ndash;3.1% observed across all vitrectomy procedures\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Furthermore, the presence of an existing PVD has been shown to lower the rate of RB during PPV across all gauge sizes and surgical indications including macular hole (MH), epiretinal membrane (ERM) and tractional retinal detachment (RD)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Some evidence also suggests that IPVD may increase the rate of postoperative rhegmatogenous RD, and this is thought to be due to missed intraoperative breaks\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite well-established literature for IPVD as a risk factor for RB during PPV, few studies explore factors that may influence this risk. There is conflicting evidence regarding the impact of surgical indication on the risk of RB. Some studies suggest ERM surgery confers a higher RB rate\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. There has been significant interest regarding differences in the effect of cannula size on RB rates in eyes undergoing vitrectomy. Some studies show higher break rates in larger gauge, higher vacuum setting surgeries, however, most show no impact from gauge size\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Few other factors that might affect RB rate in IPVD have been explored in the literature. Younger age has been shown to increase RB rate in eyes with IPVD\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePrior studies often include all vitrectomies, the majority of which do not require IPVD, making the evidence within IPVD subgroups scarce. The evidence regarding the significance of surgical indication and gauge size is supported by few relatively small-scale studies.\u003c/p\u003e \u003cp\u003eWe sought to identify risk factors for retinal breaks from a retrospective cohort of vitrectomies requiring IPVD, and to evaluate the nature and characteristics of break location in these eyes.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe reviewed the electronic medical records of all adult patients who underwent vitrectomy surgery between November 2019 and January 2024 at the Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, South Australia. Ethics committee approval was obtained from the Central Adelaide Local Health Network Human Research Ethics Committee (reference number 19813) and the study adhered to the tenets of the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eWe included all eyes which underwent pars plana vitrectomy and required intraoperative induction of posterior vitreous membrane detachment, with follow up of at least 1 month. We excluded eyes with pre-existing complete or partial PVD, those without documentation of induction techniques or intraoperative findings, eyes with previous penetrating or blunt trauma, and eyes with previous panretinal photocoagulation.\u003c/p\u003e \u003cp\u003eAll patients underwent thorough preoperative assessment including an examination for best corrected visual acuity (BCVA), slit lamp examination and dilated fundus examination.\u003c/p\u003e \u003cp\u003eThree port PPV was performed using a 25-, or 27-G vitrectomy system (Constellation Vision System, Alcon). Sclerotomies were placed 4 mm posterior to the limbus in phakic eyes and 3.5 mm in pseudophakic eyes. An infusion cannula was positioned in the inferotemporal quadrant, and supertemporal and superonasal sclerotomies were made near the 10- and 2-o\u0026rsquo;clock meridians. Absence of PVD was confirmed intraoperatively with intravitreal triamcinolone acetonide (IVTA). Induction was then performed by engagement of the attached posterior hyaloid with a 25-G or 27-G angulated dissecting needle in the area adjacent to the optic disc and elevating this in a posteroanterior direction extending at least 3-disc diameters from the margin of the optic disc. The PVD was then extended using the vitrectomy probe in a cutting mode off and a vacuum rate of 650 mmHg. Every procedure was then performed using a fixed cut rate of 5000 cuts per minute (cpm). The vacuum was set between 500 and 650 mmHg during the core vitrectomy and between 20 and 300 mmHg during peripheral vitreous removal. Surgical procedures varied after vitreous removal, depending on the pathology.\u003c/p\u003e \u003cp\u003eThe primary outcome was the occurrence of one or more non-sclerotomy-related RB. RBs were diagnosed by a careful 360-degree peripheral search of the retina using the Resight viewing system coupled with a Lumera 700 microscope. Definite RB had characteristics including an elevated retinal flap with a discrete edge. Breaks without a definite flap, edge or retinal defect observed during scleral indentation were excluded from the present study. Sclerotomy-related retinal breaks were defined as breaks occurring intraoperatively that were located near 1 of the 3 sclerotomies (within 1 hour either side of the sclerotomy site) and were recorded but excluded from the main analysis. We included any breaks identified up to 1 month following surgery that fit these criteria. All iatrogenic breaks were treated with laser photocoagulation. If breaks were round or had significant underlying pigment surrounding them, they were categorised as pre-existing and excluded from the study.\u003c/p\u003e \u003cp\u003eData collected included demographic, clinical, surgical and post-operative findings. Patient demographics included age and sex, ocular history, prior surgical history in subject eye, history of retinal breaks or detachment, and history of diabetes with proliferative diabetic retinopathy or tractional retinal detachment. Clinical factors included laterality, phakic status, intraocular pressure (IOP), BCVA (Snellen in metres). Surgical factors included the surgery indication, surgeon seniority/grade, instrument gauge size, retinal breaks, if encountered, including their location and whether they were sclerotomy-related or breaks elsewhere.\u003c/p\u003e \u003cp\u003eContinuous variables such as age were described using mean and standard deviation (SD) or median and interquartile range (IQR). Categorical variables such as gender, surgical indication, instrument gauge size, and surgeon grade, were summarized using frequencies and percentages.\u003c/p\u003e \u003cp\u003eModified generalized estimating equations logistic regression (to account for inter-eye correlation) was used to explore the association of exposures with odds of RB. Exposure variables were adjusted for the precision variable age, identified a priori from literature as a previously known risk factor and was the minimally sufficient adjustment set for all exposure of interest after the construction of directed acyclic graphs to map potential variable relationships (Supplement Fig.\u0026nbsp;1)\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. We assessed the direct effect of age, gauge size (25-G vs 27-G), surgical indication (MH/VMTS vs ERM vs VH vs Other) and phakic status (Phakic vs Aphakic/Pseudophakic) on odds of RB, adjusted for age. Data reduction of the surgical indication variable was performed by combining VMTS and MH, and with phakic status by combining aphakia and pseudophakia. Results were reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs).\u003c/p\u003e \u003cp\u003eAll statistical analyses were performed using the statistical programming language R (packages geessbin v0.1.2, glmtoolbox v0.1.11)\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. P values were not adjusted for multiple testing due to the study's exploratory nature.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe included 253 eyes of 244 patients in the study cohort (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The cohort included 123 females (50%) and 121 males (50%). The median age was 69 (Range 18\u0026ndash;94, IQR 61\u0026ndash;77).\u003c/p\u003e \u003cp\u003eThere were 204 phakic eyes (81%), 46 pseudophakic eyes (18%), and 3 aphakic eyes (1%). There were 2 eyes with other previous intraocular surgery excluding phacoemulsification and intraocular lens implant, which included 1 case of trabeculectomy and 1 case of extracapsular lens extraction following traumatic cataract. The median preoperative BCVA was 0.70 (IQR 0.5\u0026ndash;2.00) logMAR, i.e. 6/30 (IQR (6/19\u0026ndash;6/600).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical and surgical characteristics of included eyes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo RB, N\u0026thinsp;=\u0026thinsp;210\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRB, N\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaterality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109 (52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (51%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (49%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior Intraocular Surgery (excluding cataract)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208 (99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhakic Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAphakic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhakic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e173 (82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (72%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudophakic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCVA (logMAR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.70 (0.50, 1.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90 (0.55, 2.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Indication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMH/VMTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgeon Grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFellow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e194 (92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (98%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGauge Size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131 (62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (93%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious RB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e207 (99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eBCVA: best corrected visual acuity. RB\u0026thinsp;=\u0026thinsp;retinal break\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eVitrectomies were performed either by a fellow retinal surgeon in 236 (93%) of cases, or a consultant retinal surgeon in 17 (7%) cases. The indication for surgery was MH in 44%, ERM in 26%, VH in 13%, RD or TRD in 7%, dropped or subluxed IOL/lens in 6%, VMTS in 2%, symptomatic vitreous opacity surgery in 1 (0.5%), and diagnostic vitrectomy in 1 eye (0.5%). The cannulation gauge used was 25-G in 68%, 27-G PPV in 32%.\u003c/p\u003e \u003cp\u003eIn total there were 65 peripheral RB that occurred in 43 (17%) eyes during induction of PVD (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All breaks occurred intraoperatively, none were detected in the postoperative follow up. Of the 65 breaks, 16 (25%) were described as inferior, 12 (18%) were inferonasal, 10 (15%) were inferotemporal, 10 (15%) were superotemporal, 4 (6%) were nasal, 4 (6%) were superonasal, 3 (5%) were superior, 2 (3%) were temporal, 1 (2%) was peripheral, and 3 (5%) were not reported. There were 3 cases of sclerotomy-related RBs which occurred in three eyes (1.2%). Two of these were described as superotemporal, and one was superonasal.\u003c/p\u003e \u003cp\u003eOf the eyes that experienced peripheral RB, 40/43 (93%) had 25-G surgery and 3/43 (7%) had 27-G surgery. The RB rate for 25-G and 27-G cannulation systems was 58/171 (34%) and 7/82 (8.5%), respectively. Most RB occurred in phakic eyes (72%) of cases. The presence of RB by surgical indication was 15/112 (13%) for MH, 12/67 (18%) for ERM, 7/33 (21%) for VH, 3/14 (20%) for RD, 2/3 (67%) for dropped nucleus with retained lens matter, 2/3 (67%) for TRD, 1/6 (17%) for VMTS and 1/4 (25%) for subluxed IOL.\u003c/p\u003e \u003cp\u003eIncreasing age was not associated with a reduced odds of RB (OR 0.98, p\u0026thinsp;=\u0026thinsp;0.069, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Gauge size of 27-G compared to 25-G was associated with reduced odds of RB in unadjusted and adjusted analyses (Adjusted OR 0.14, p\u0026thinsp;=\u0026thinsp;0.0003). Neither lens status, surgical indication, nor surgeon grade was associated with odds of RB (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable generalised estimating equations logistic regression estimating the direct effect of hypothesised exposures on the odds of RB during IPVD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnadjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98 (0.96\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGauge Size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.14 (0.05\u0026ndash;0.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.14 (0.05\u0026ndash;0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Indication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMH/VMTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.72 (0.31\u0026ndash;1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.70 (0.30\u0026ndash;1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 (0.55-3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1 (0.44\u0026ndash;2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLens Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAphakic/Pseudophakic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhakic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.55 (0.25\u0026ndash;1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.47 (0.21\u0026ndash;1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgeon Grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFellow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4 (0.52\u0026ndash;11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.5 (0.52-12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOR: Odds ratio. CI: confidence interval. G: gauge. ERM: epiretinal membrane. MH: macular hole. VMTS: vitreomacular traction syndrome. IPVD: Induction of posterior vitreous detachment. Adjusted models are adjusted for age (as a linear variable).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIPVD is a known risk factor for RB during PPV\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. The rate of IPVD-associated RB in our cohort of eyes was 17%, with 58% of these breaks occurring in the inferior retina. The frequency of RB in our eyes was in keeping with past evidence in similar patient populations of 9.02\u0026ndash;32.1%\u003csup\u003e1,7,10\u003c/sup\u003e. We found that cannulation gauge size significantly impacted the rate of RB. Other demographic, patient and procedural factors including age, lens status, surgical indication and surgeon grade did not impact the odds of RB.\u003c/p\u003e \u003cp\u003eThere is conflicting evidence in literature regarding the impact of cannulation size on the rate of RB during IPVD. Most studies have demonstrated no effect of gauge size on RB rates in IPVD. Hikichi et al. performed a single surgeon retrospective review in a series of 183 eyes undergoing either MH or ERM surgery and found equal rates of RB between 20-G and 23-G surgery (20/122 (16%) vs. 10/61 (16%))\u003csup\u003e14\u003c/sup\u003e. Sandali et al. reported comparable rates of RB across 553 eyes undergoing ERM surgery requiring IPVD using either 20-G, 23-G or 25-G cannulation, however no statistical analysis of the IPVD subgroup was performed (20-G 12.34% vs. 23-G 13.9% vs. 25-G 5.3%)\u003csup\u003e9\u003c/sup\u003e. The findings of these studies are limited by the small number of eyes requiring IPVD, and lack of an IPVD subgroup analysis. In contrast, Nakano et al. found that larger 20-G surgery experienced a higher RB rate compared to 23-G. The authors compared the RB rate in a series of 225 eyes requiring ERM surgery and 103 requiring MH surgery undergoing either 20-G or 23-G cannulation technique\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Vitreous cut rate was fixed at 2000 cpm with maximum aspiration pressure up to 500 mmHg for both 20-G and 23-G when inducing PVD. In eyes requiring IPVD, the incidence of iatrogenic RB was 15.8% in the 20-G group and 3.1% in the 23-G group (p\u0026thinsp;=\u0026thinsp;0.0234). This finding may be limited by no distinction made between sclerotomy related breaks and breaks elsewhere. Our results demonstrate a significant impact of gauge size on RB rate, with eyes undergoing 27-G surgery having a significantly lower RB rate than those undergoing 25-G. Gauge size may have an effect through various mechanisms. It is thought that sclerotomy related breaks are due to incarceration of vitreous gel around sclerotomy sites, increasing retinal traction\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Iatrogenic non-entry site peripheral breaks on the other hand, are generally regarded to be secondary to the creation and extension of PVD intraoperatively and their pathogenesis is incompletely understood. The higher RB rate in 25-G surgery has previously been explained by the relatively higher vacuum settings of larger gauge surgeries, which can increase retinal traction and the propensity for RB development. However, in our series of eyes vacuum settings for both 25-G and 27-G surgery was set at 650 mmHg. Possibly the reduced cut diameter and lower duty cycle in 27-G surgery may contribute to improved fluid dynamics. Previous studies have demonstrated lower IOP fluctuations in 27-G vitrectomy compared to 25-G, regardless of the aspiration system used\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The higher flow limitations of cutter gauge size, port size and duty cycle may be an advantage with smaller gauge surgeries, whereby there is reduced average vitreous fibre travel between cuts, limiting the traction exerted on the retina\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. The increase in fluid turbulence in 25-G may also affect retinal stability and increase the risk of RB\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Additionally, 25-G instruments have higher rigidity compared to 27-G, which may increase retinal manipulation especially in the peripheries where instrument flexibility is required\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePrevious studies have demonstrated higher RB rates in younger patients undergoing IPVD, despite finding no association in our results\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Rahman et al. investigated a series of 137 patients undergoing IPVD with an age range of 32\u0026ndash;94 years (mean 69.9), and revealed each 1-year increase in age was associated with 4.1% decreased odds of a RB (OR 0.959, p\u0026thinsp;=\u0026thinsp;0.028)\u003csup\u003e10\u003c/sup\u003e. Additionally, they found that eyes with an adherent posterior hyaloid, defined as requiring membrane blue with targeted suction, were 3.8 times more likely to experience a RB. They did not investigate the association of age and likelihood of an adherent PHF, however this association has been well-established in other studies\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Ageing has been associated with partial detachment of PVD, which may lower the suction requirements during IPVD\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. However, in our series of eyes we found that increasing age was not statistically associated with a reduction in the odds of experiencing a RB during IPVD (OR 0.98, p\u0026thinsp;=\u0026thinsp;0.069). Despite an age range of 18\u0026ndash;94 years, the older age skew within our study may limit the ability to properly examine the effect of age on RB rate.\u003c/p\u003e \u003cp\u003eWe found surgical indication was not associated with an increased odds of RBs, across a wide range of conditions requiring PPV, consistent with existing literature. Chung et al. found no difference in RB rate between eyes undergoing IPVD for ERM or MH surgery (32.1% (9/28) vs. 12.7% (19/105), p\u0026thinsp;=\u0026thinsp;0.0563, respectively)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Rahman et al. also revealed no association between diagnosis and increased RB rate across 137 eyes undergoing vitrectomy\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Other studies have shown mixed findings. Nakano et al. demonstrated a higher rate of RB in 84 eyes undergoing MH surgery compared to 38 eyes undergoing ERM (13% vs. 0%), whilst Mura et al. reported ERM may have the highest RB rate across a range of indications (4.2%, 8/189 compared to 1.9%, 2/106 VMTS in the next highest category)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. However, these studies do not include an IPVD subgroup analysis.\u003c/p\u003e \u003cp\u003eWe found a high proportion of peripheral RB experienced during IPVD were in the inferior retinal field. Of the 65 breaks, 58% (38/65) of breaks were in the inferior retina, compared to only 26.2% (17/65) in the superior retina. Previous studies have reported similar findings. Sandali et al. revealed within the subgroup of eyes requiring IPVD, there was a higher portion of RB that occurred in the inferior retina compared to superior retina, irrespective of gauge size and indication (81.2% vs. 19.0%)\u003csup\u003e9\u003c/sup\u003e. Hikichi et al. also found a significantly higher number of inferior quadrant breaks compared to superior quadrant breaks in eyes requiring IPVD undergoing 23-G surgery (68% vs. 32%, p\u0026thinsp;=\u0026thinsp;0.014)\u003csup\u003e14\u003c/sup\u003e. The proposed mechanism is the physiological direction of PVD. Naturally occurring PVD begins superiorly and extends inferiorly, often resulting in incomplete or partial vitreo-retinal dehiscence in inferior quadrants\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Schneider et al. have suggested that as the vitreous undergoes physiological liquefaction and begins detaching, collagen fibrils aggregate into parallel bundles that form thicker adhesions, preventing a complete PVD inferiorly\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The higher degree of inferior retinal traction may explain the high inferior RB rate seen in our series of eyes. However, given the exclusion of sclerotomy-related breaks, the greater arc angle inferonasally could introduce a selection bias in the distribution of RBs. Despite this, sclerotomy-related breaks were only experienced in 3 eyes (1.2%), which is in keeping with previous evidence\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA strength of our study is the inclusion of only eyes requiring IPVD, which have been included only as a subgroup analyses in past studies. The implications of this research could improve preoperative risk counselling and may influence the surgical approach to eyes requiring IPVD. Our findings are limited by the retrospective nature of the study.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis retrospective study revealed a high rate of RB breaks in eyes undergoing PPV which require IPVD (17%). We found that 25 G compared to 27 G surgery increased the odds of experiencing a RB during IPVD. Other factors including age, lens status, surgical indication and grade of surgeon did not impact the odds of RB. The proportion of breaks located inferiorly was high (58%). Our results add further evidence regarding risk factors for RB during IPVD.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eRoyal Adelaide Hospital Retina Research Group\u003c/p\u003e\n\u003cp\u003eWeng Onn Chan (MB ChB MPhil FRANZCO), Shane Durkin (MBBS(Hons), MPHC, MMed(OphthSc), FRANZCO), Jagjit Gilhotra (MBBS, FRANZCO), David Sia (MB ChB FRANZCO), Carmelo Macri (MBBS, MPhil)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest or competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship contribution Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJai Paris\u003c/strong\u003e – Writing – review \u0026amp; editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data collection \u0026amp; curation, Visualisation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCarmelo Macri\u003c/strong\u003e – Writing – review \u0026amp; editing, Supervision, Methodology, Investigation, Formal analysis, Data collection \u0026amp; curation, Visualisation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurbhi Agrawal –\u003c/strong\u003e Writing – review \u0026amp; editing, Supervision, Formal analysis\u003c/p\u003e\n\u003cp\u003eStewart Lake – Writing – review \u0026amp; editing, Supervision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWeng Onn Chan\u003c/strong\u003e – Writing - review \u0026amp; editing, Supervision, Formal analysis, Conceptualisation\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eChung SE, Kim KH, Kang SW. Retinal breaks associated with the induction of posterior vitreous detachment. \u003cem\u003eAm J Ophthalmol\u003c/em\u003e. Jun 2009;147(6):1012-6. doi:10.1016/j.ajo.2009.01.013\u003c/li\u003e\n \u003cli\u003eMura M, Barca F, Dell\u0026apos;Omo R, Nasini F, Peiretti E. Iatrogenic retinal breaks in ultrahigh-speed 25-gauge vitrectomy: a prospective study of elective cases. \u003cem\u003eBr J Ophthalmol\u003c/em\u003e. 10 2016;100(10):1383-7. doi:10.1136/bjophthalmol-2015-307654\u003c/li\u003e\n \u003cli\u003eDogramaci M, Lee EJ, Williamson TH. The incidence and the risk factors for iatrogenic retinal breaks during pars plana vitrectomy. \u003cem\u003eEye (Lond)\u003c/em\u003e. May 2012;26(5):718-22. doi:10.1038/eye.2012.18\u003c/li\u003e\n \u003cli\u003eTan HS, Mura M, de Smet MD. Iatrogenic retinal breaks in 25-gauge macular surgery. \u003cem\u003eAm J Ophthalmol\u003c/em\u003e. Sep 2009;148(3):427-30. doi:10.1016/j.ajo.2009.04.002\u003c/li\u003e\n \u003cli\u003eGuillaubey A, Malvitte L, Lafontaine PO, et al. Incidence of retinal detachment after macular surgery: a retrospective study of 634 cases. \u003cem\u003eBr J Ophthalmol\u003c/em\u003e. Oct 2007;91(10):1327-30. doi:10.1136/bjo.2007.115162\u003c/li\u003e\n \u003cli\u003eCarter JB, Michels RG, Glaser BM, De Bustros S. Iatrogenic retinal breaks complicating pars plana vitrectomy. \u003cem\u003eOphthalmology\u003c/em\u003e. Jul 1990;97(7):848-53; discussion 854. doi:10.1016/s0161-6420(90)32492-2\u003c/li\u003e\n \u003cli\u003eNakano T, Uemura A, Sakamoto T. Incidence of iatrogenic peripheral retinal breaks in 23-gauge vitrectomy for macular diseases. \u003cem\u003eRetina\u003c/em\u003e. Nov 2011;31(10):1997-2001. doi:10.1097/IAE.0b013e31820f49ea\u003c/li\u003e\n \u003cli\u003eJalil A, Ho WO, Charles S, Dhawahir-Scala F, Patton N. Iatrogenic retinal breaks in 20-G versus 23-G pars plana vitrectomy. \u003cem\u003eGraefes Arch Clin Exp Ophthalmol\u003c/em\u003e. Jun 2013;251(6):1463-7. doi:10.1007/s00417-013-2299-2\u003c/li\u003e\n \u003cli\u003eSandali O, El Sanharawi M, Lecuen N, et al. 25-, 23-, and 20-gauge vitrectomy in epiretinal membrane surgery: a comparative study of 553 cases. \u003cem\u003eGraefes Arch Clin Exp Ophthalmol\u003c/em\u003e. Dec 2011;249(12):1811-9. doi:10.1007/s00417-011-1752-3\u003c/li\u003e\n \u003cli\u003eRahman R, Murray CD, Stephenson J. Risk factors for iatrogenic retinal breaks induced by separation of posterior hyaloid face during 23-gauge pars plana vitrectomy. \u003cem\u003eEye (Lond)\u003c/em\u003e. May 2013;27(5):652-6. doi:10.1038/eye.2013.6\u003c/li\u003e\n \u003cli\u003eTeam RC. A Language and Environment for Statistical Computing. R Foundation for Statistical Computing,. Vienna, Austria2023.\u003c/li\u003e\n \u003cli\u003eVanegas LH. Set of Tools to Data Analysis using Generalized Linear Models, Package \u0026lsquo;glmtoolbox\u0026rsquo;. In: Rond\u0026oacute;n LM, editor. 2024.\u003c/li\u003e\n \u003cli\u003eIshii R. Modified Generalized Estimating Equations for Binary Outcome. In: Ohigashi T, editor. 2023.\u003c/li\u003e\n \u003cli\u003eHikichi T, Kosaka S, Takami K, et al. Incidence of retinal breaks in eyes undergoing 23-gauge or 20-gauge vitrectomy with induction of posterior vitreous detachment. \u003cem\u003eRetina\u003c/em\u003e. Jun 2012;32(6):1100-5. doi:10.1097/IAE.0b013e3182349449\u003c/li\u003e\n \u003cli\u003eSato T, Kusaka S, Oshima Y, Fujikado T. Analyses of cutting and aspirating properties of vitreous cutters with high-speed camera. \u003cem\u003eRetina\u003c/em\u003e. May 2008;28(5):749-54. doi:10.1097/IAE.0b013e3181631907\u003c/li\u003e\n \u003cli\u003eShinkai Y, Yoneda K, Sotozono C. Ex vivo Comparison of Intraocular Pressure Fluctuation during Pars Plana Vitrectomy Performed Using 25- and 27-Gauge Systems. \u003cem\u003eOphthalmic Res\u003c/em\u003e. 2022;65(2):210-215. doi:10.1159/000511948\u003c/li\u003e\n \u003cli\u003eMagalhaes O, Chong L, DeBoer C, et al. Vitreous dynamics: vitreous flow analysis in 20-, 23-, and 25-gauge cutters. \u003cem\u003eRetina\u003c/em\u003e. Feb 2008;28(2):236-41. doi:10.1097/IAE.0b013e318158e9e0\u003c/li\u003e\n \u003cli\u003eSteel DH, Charles S. Vitrectomy fluidics. \u003cem\u003eOphthalmologica\u003c/em\u003e. 2011;226 Suppl 1:27-35. doi:10.1159/000328207\u003c/li\u003e\n \u003cli\u003eHubschman JP, Gupta A, Bourla DH, Culjat M, Yu F, Schwartz SD. 20-, 23-, and 25-gauge vitreous cutters: performance and characteristics evaluation. \u003cem\u003eRetina\u003c/em\u003e. Feb 2008;28(2):249-57. doi:10.1097/IAE.0b013e31815ec2b3\u003c/li\u003e\n \u003cli\u003eJoshi MM, Ciaccia S, Trese MT, Capone A. Posterior hyaloid contracture in pediatric vitreoretinopathies. \u003cem\u003eRetina\u003c/em\u003e. Sep 2006;26(7 Suppl):S38-41. doi:10.1097/01.iae.0000244287.63757.5a\u003c/li\u003e\n \u003cli\u003eSyed Z, Stewart MW. Age-dependent vitreous separation from the macula in a clinic population. \u003cem\u003eClin Ophthalmol\u003c/em\u003e. 2016;10:1237-43. doi:10.2147/OPTH.S99635\u003c/li\u003e\n \u003cli\u003eShaimova VA, Kuchkildina SK, Islamova GR, Arslanov GM, Kravchenko TG, Askaeva AA. [Age-related changes in human vitreous]. \u003cem\u003eVestn Oftalmol\u003c/em\u003e. 2023;139(3):106-111. doi:10.17116/oftalma2023139031106\u003c/li\u003e\n \u003cli\u003eSchneider EW, Johnson MW. Emerging nonsurgical methods for the treatment of vitreomacular adhesion: a review. \u003cem\u003eClin Ophthalmol\u003c/em\u003e. 2011;5:1151-65. doi:10.2147/OPTH.S14840\u003c/li\u003e\n \u003cli\u003eTarantola RM, Tsui JY, Graff JM, et al. Intraoperative sclerotomy-related retinal breaks during 23-gauge pars plana vitrectomy. \u003cem\u003eRetina\u003c/em\u003e. Jan 2013;33(1):136-42. doi:10.1097/IAE.0b013e31825e1d62\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Posterior Vitreous Detachment, Retinal Break, Vitrectomy, Surgical Technique, Retinal Detachment, Risk Factors","lastPublishedDoi":"10.21203/rs.3.rs-6223838/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6223838/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eTo determine risk factors for retinal breaks (RB) during the surgical induction of posterior vitreous detachment (IPVD).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe retrospectively reviewed electronic records for all adult patients undergoing 25-G or 27-G vitrectomy surgery between November 2019 and January 2024 requiring intraoperative IPVD. We excluded eyes with pre-existing PVD, panretinal photocoagulation, trauma, or missing information. The outcome measure was non-sclerotomy-related iatrogenic RB. We assessed the effect of age, gauge size (25-G vs 27-G), surgical indication (epiretinal membrane [ERM] vs macular hole[MH]/vitreomacular traction syndrome[VMTS] vs Other), lens status (Phakic vs Aphakic/Pseudophakic) and surgeon (Consultant vs Fellow) on the odds of RB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong 253 eyes included in our study, 17% experienced a RB during IPVD. Breaks were predominantly located in the inferior retina (58%). Multivariable analysis revealed gauge size significantly impacted RB rate (27G OR 0.14, 95%CI 0.05-0.40, p = 0.0003). Other factors including age (OR 0.98, 95%CI 0.96-1, p = 0.069), lens status (Phakic OR 0.47, 95%CI 0.21-1.1, p = 0.068), surgeon grade (Fellow OR 2.5 95%CI 0.52-12, p = 0.25) and surgical indication (MH OR 0.70 95%CI 0.30-1.6, p = 0.40) were not significantly associated with odds of RB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThere is a high rate of iatrogenic RB in eyes requiring IPVD. Smaller instrument gauge size reduced the odds of RB. Neither age, surgical indication nor lens status were associated with odds of RB.\u003c/p\u003e","manuscriptTitle":"Risk Factors for Iatrogenic Retinal Breaks in Eyes Requiring Surgical Induction of Posterior Vitreous Detachment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 09:16:51","doi":"10.21203/rs.3.rs-6223838/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7286e387-6679-49ce-b05a-d17bbcc6ad77","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48060719,"name":"Health sciences/Health care/Therapeutics/Surgery"},{"id":48060720,"name":"Health sciences/Diseases/Eye diseases/Vitreous detachment"}],"tags":[],"updatedAt":"2025-08-29T07:56:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-08 09:16:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6223838","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6223838","identity":"rs-6223838","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}