Rhegmatogenous Retinal Detachment

Background
Retinal detachment occurs when subretinal fluid accumulates in the potential space between the
neurosensory retina and the underlying retinal pigment epithelium (RPE). Depending on the mechanism of
subretinal fluid accumulation, retinal detachments traditionally have been classified into rhegmatogenous,
tractional, and exudative.
The term rhegmatogenous is derived from the Greek word rhegma, which means a discontinuity or a break.
A rhegmatogenous retinal detachment (RRD) occurs when a tear in the retina leads to fluid accumulation
with a separation of the neurosensory retina from the underlying RPE; this is the most common type of
retinal detachment.

Pathophysiology
Vitreoretinal traction is responsible for the occurrence of most RRD. As the vitreous becomes more
syneretic (liquefied) with age, a posterior vitreous detachment (PVD) occurs. In most eyes, the vitreous gel
separates from the retina without any sequelae. However, in certain eyes, strong vitreoretinal adhesions
are present and the occurrence of a PVD can lead to a retinal tear formation; then, fluid from the liquefied
vitreous can seep under the tear, leading to a retinal detachment.
A number of conditions exist that predispose to a PVD by prematurely accelerating the liquefaction of the
vitreous gel. Myopia, aphakia or pseudophakia, familial conditions, and inflammation are among the
common causes. In other cases, retinal necrosis with a retinal break formation occurs; then, fluid from the
vitreous cavity can flow through the breaks and detach the retina without there being overt vitreoretinal
traction present. This commonly occurs in acute retinal necrosis syndrome and in cytomegalovirus (CMV)
retinitis in AIDS patients.

Epidemiology
Frequency
United States
According to population-based studies in Iowa by Haimann et al and in Minnesota by Wilkes et al, the
annual incidence of RRD is 12 cases per 100,000. [1, 2]
International
Scandinavian studies by Laatikainen et al and Tornquist et al reveal an annual incidence of RRD of 7-10
cases per 100,000.[3, 4]
A Japanese study by Sasaki et al reported an annual incidence of RRD of 10.4 cases per 100,000. [5]
A study from Singapore by Wong et al reported annual incidences of RRD of 11.6 cases per 100,000 in the
Chinese population, 7 cases per 100,000 in the Malay population, and 3.9 cases per 100,000 in the Indian
population.[6]
A study from Beijing, China, estimated the annual incidence of RRD to be 7.98 cases per 100,000.
The annual incidence of RRD in the Netherlands during 2009 was reported to be 18.2 cases per 100,000
people. The peak incidence of 52.5 cases per 100,000 people was found in persons aged 55-59 years. [7]

Mortality/Morbidity
Visual results depend on the preoperative macular status. Most series report an anatomical success rate of
90-95%. Of the eyes that are successfully reattached, about 50% obtain a final visual acuity of 20/50 or
better. In eyes where the macula was attached prior to surgery, as many as 10% have some vision loss
despite successful surgery. In most cases, this decrease in vision is caused by cystoid macular edema and
macular pucker.

Sex
RRD appears to be more common in males than in females.

Age

Most RRDs occur in persons aged 40-70 years. It is at this time that the syneretic vitreous undergoes
separation from the retina.
Clinical Presentation

History
Specifically ask patients about risk factors that predispose to premature PVD.

Myopia
Prior intraocular surgery
Family history
RRD in the fellow eye

Photopsias
Photopsias refer to the perception of flashing lights by the patient. It probably arises from the mechanical
stimulation of vitreoretinal traction on the retina. It may be induced by eye movements and appears to be
more noticeable in dim illumination.

Visual field defect

Patients often describe a black curtain (visual field defect) once the subretinal fluid extends posterior to the
equator.

Floaters
Floaters are opacities in the vitreous that cast a dark shadow according to their form and shape in the
patient's visual field as they float in the vitreous cavity.
A ring-shaped floater is the Weiss ring or the remnant of the hyaloid that was attached to the edges of the
optic disc.
Cobwebs are caused by condensation of the collagen fibers.
Small spots usually indicate fresh blood due to the rupture of a retinal vessel during an acute PVD.

Loss of central vision

When the macula becomes detached (ie, extension of subretinal fluid into the macula), the patient
experiences a drop in visual acuity.
In other cases, a large bullous detachment may obstruct the macula, causing decreased visual acuity
despite the fact that the macula is not detached.

Physical
Cell and flare may be seen in the anterior chamber of eyes with a rhegmatogenous retinal detachment
(RRD).
The intraocular pressure is usually lower in the eye with a RRD than in the fellow eye; this is usually
reversed by retinal reattachment. In certain cases, the intraocular pressure may be higher than in the fellow
eye.
Pigment in the anterior vitreous (tobacco dusting or a Shaffer sign) is usually present.
Once the retina becomes detached, it assumes a slightly opaque color secondary to intraretinal edema. It
has a convex configuration, has a corrugated appearance, and undulates freely with eye movements
unless severe proliferative vitreoretinopathy (PVR) is present.
A retinal break in the shape of a horseshoe or flap is often present. Of all RRDs, 50% have more than 1
break. Of all breaks, 60% are located in the upper temporal quadrant, and 15% are located in the upper
nasal quadrant. Another 15% are in the lower temporal quadrant, and 10% are in the lower nasal quadrant.
Chronic RRD may present with retinal thinning, intraretinal cysts, subretinal fibrosis, and demarcation lines.
These lines are usually at the junction of attached and detached retina. Even though they represent areas
of increased retinal adhesion to the RPE, it is not uncommon for subretinal fluid to spread beyond the lines.
Rhegmatogenous retinal detachment is shown in the images below.

Clinical picture of a rhegmatogenous retinal

detachment involving the macula. Notice the folds just temporal to the fovea.

Clinical picture of a rhegmatogenous retinal

detachment. Notice that the macula is involved and that the retina is corrugated and has a slightly opaque color.

Causes
The main cause of a rhegmatogenous retinal detachment (RRD) is a PVD that leads to retinal tear
formation. The following are risk factors that commonly share the premature liquefaction of the vitreous gel
leading to an increased rate of PVD.
Abnormal vitreoretinal adhesions, which may be visible or invisible, are present in many eyes. Among the
visible ones are enclosed oral bays, lattice degeneration, and cystic retinal tufts. When a PVD occurs and
encounters such an area, a retinal tear may form.
Prior intraocular surgery, especially cataract extraction: It appears that an intact posterior capsule delays
the onset of PVD. Other procedures, such as penetrating keratoplasty and pars plana vitrectomy (PPV),
also may be complicated by a RRD.
Certain familial conditions, such as Stickler syndrome, Marfan syndrome, homocystinuria, and EhlersDanlos syndrome, are associated with RRD.
Inflammatory or infectious conditions, such as acute retinal necrosis syndrome, CMV retinitis in AIDS
patients, ocular toxoplasmosis, and pars planitis
Axial myopia may be noted.

Differential Diagnoses

Acute Retinal Necrosis

CMV Retinitis

Exudative Retinal Detachment

Postoperative Retinal Detachment

Proliferative Retinal Detachment

Senile Retinoschisis

Tractional Retinal Detachment

Imaging Studies

Ultrasound

On certain occasions, the media may not be clear, impairing a thorough retinal examination with
the binocular indirect ophthalmoscope. An ultrasound is a useful adjunct in these situations.
Ultrahigh-frequency sounds travel to the back of the eye as the probe emits them. Once a
structure is contacted by the sound waves, the sound wave is attenuated and reflected back to the
probe. The pattern of these waves is specific for certain tissues. Thus, localization and tissue
characterization is possible using this technique. Typically, an A scan and a B scan are obtained.
For instance, retinal tissue usually shows a large spike in the A scan, reflecting an increased
acoustic density of the tissue. The B scan shows a composite picture of the globe and its
intraocular contents.
Sometimes, it may be difficult to differentiate a retinal detachment from a thickened, partially
detached posterior hyaloid. In this case, A-scan and B-scan findings often overlap. Tissue mobility
during scanning may help to differentiate the two. Usually, a RRD has a characteristic undulating
motion after a sudden saccade, whereas a thickened posterior hyaloid moves in a brisker manner
but with less excursion. Results from a B scan are shown below.

This patient had a vitreous

hemorrhage that prevented visualization of the retina. A B-scan ultrasound reveals a retinal detachment.

Fluorescein angiography (FA)

Cystoid macular edema may complicate the postoperative course of an eye that has undergone
retinal reattachment surgery. FA is a useful adjunct in helping to diagnose this condition.

Optical coherence tomography (OCT)

Occasionally, certain eyes appear to have complete retinal reattachment, but the visual acuity
recovery appears to be incomplete or delayed. OCT helps to reveal subfoveal fluid in these eyes. [8]

Other Tests

Electroretinogram (ERG)

When a patient presents with a dense vitreous hemorrhage or a cataract that precludes direct
visualization of the retina, an ultrasound of the posterior pole is indicated. Sometimes,
differentiating a RRD and a thickened posterior hyaloid that is partially detached using ultrasound
is difficult. In these circumstances, an ERG is a useful adjunct in the evaluation of a patient
suspected of having a RRD. If a good response from the ERG is obtained, the retina is probably
attached. If the electric response from the retina is attenuated to a great degree, the retina is
probably detached.

Histologic Findings

During separation of the neurosensory retina from the RPE, the choroidal blood flow to the outer
retinal layers is lost. The RPE also loses its ability to modulate the health of the outer segments of
the photoreceptors. Initially, the outer segments of the photoreceptors are lost. After successful
retinal reattachment, the outer segments may regenerate. As the detachment becomes more
chronic, atrophy of the entire photoreceptor layer, cystic degeneration, macrocyst formation,
demarcation lines, and even rubeosis iridis may be seen.
Treatm

Medical Care
No role exists for medical care in the treatment of rhegmatogenous retinal detachments (RRDs).

Surgical Care
Regardless of the surgical technique chosen, the surgical goals are to identify and close all the breaks with
minimum iatrogenic damage. Closure of the breaks occurs when the edges of the retinal break are brought
into contact with the underlying RPE. This is accomplished either by bringing the eye wall closer to the
detached retina (a scleral buckle) or by pushing the detached retina toward the eye wall (intraocular
tamponade with a gas bubble). Sealing of the breaks is accomplished by creating a strong chorioretinal
adhesion around the breaks; this may be completed with diathermy, cryotherapy, or laser photocoagulation.
During diathermy, an alternating electrical current of 13.56 MHz is generated. As the current passes
through the tissue, resistance of the tissue gives rise to heat. This heat coagulates the tissue. Diathermy
produces an adequate RPE adhesion, but it produces immediate scleral shrinkage with subsequent scleral
necrosis. This leads to complications during reoperations and an increased rate of scleral abscess
formation. Diathermy is generally used during implant procedures.
Cryotherapy avoids all the complications of diathermy. However, it breaks down the blood-ocular barrier
and may cause dispersion of RPE cells into the vitreous cavity, which may contribute to PVR. Following
cryotherapy, the retinal RPE adhesion is usually weaker during the first week, but, by the end of the second
week, the adhesion attains its strongest strength.
Laser photocoagulation causes the least morbidity. However, it requires the retina to be flat over the RPE
before a chorioretinal adhesion can be formed. The adhesion attains its maximum strength at 7 days.
Scleral buckles usually are made of solid silicone and silicone sponges. Other materials, such as fascia
lata, gelatin, and preserved sclera, have been used at different times for scleral buckling.

Scleral explant
Initially, Custodis described this technique, which Lincoff later modified. [9, 10]
A conjunctival peritomy is performed with isolation of the recti muscles.
Indirect ophthalmoscopy is used to localize all the breaks. Once the breaks are localized, they are usually
treated with cryotherapy.
A buckling element is chosen and sutured over the breaks.
The surgeon decides whether to drain the subretinal fluid. The buckle is adjusted to an appropriate height.
The central retinal artery is monitored carefully during this maneuver.

In cases where the subretinal fluid is not drained, an anterior chamber paracentesis and/or liquid vitreous
removal is performed.
Postoperative visual acuity seems to show a worse prognosis if the repair is performed after 6 days of a
macula-off RRD.

Scleral implant
Schepens popularized this method.[11]
A conjunctival peritomy is performed with isolation of the recti muscles.
Indirect ophthalmoscopy is used to localize all the breaks. A partial lamellar scleral resection is performed
in the area of the breaks.
Diathermy is used to create a chorioretinal adhesion.
A scleral implant is chosen and put in the bed of the dissected sclera.
Drainage of the subretinal fluid is undertaken.
The sclera is sutured over the implant.

Drainage versus no drainage

The drainage of the subretinal fluid is a controversial topic among vitreoretinal specialists. Reasons given
for drainage include reduction in intraocular volume, which allows elevation of the buckle without the
problems of increased intraocular pressure and settling of the breaks on the buckle allowing rapid closure
of the breaks.
Complications during drainage include choroidal hemorrhage, retinal perforation, retinal incarceration, and
choroidal neovascularization.
Arguments against drainage involve the avoidance of the complications of the drainage procedure. Studies
by Chignell et al and Lincoff et al have shown that nondrainage procedures work as well as drainage
procedures.[12, 13] In these patients, intraocular pressure must be monitored carefully. Most of these patients
require a paracentesis or removal of liquid vitreous to elevate the buckle without choking off the central
retinal artery. In addition, the subretinal fluid may take longer to reabsorb.

Complications
See the list below:

Postoperative glaucoma: Angle closure may occur secondary to a detachment and an anterior
displacement of the ciliary body. Medical therapy is instituted as required. If this does not work, laser
iridotomy followed by laser iridoplasty may be tried to open up the angle.
Anterior segment ischemia: Patients at risk are those with sickle cell (SC) hemoglobinopathy and
high encircling buckles. Mild cases may respond to topical or systemic steroids, but the encircling band
needs to be cut in other cases.
Infection and extrusion of the buckle probably occur in 1% of cases. In these cases, the buckle
needs to be removed.
Choroidal detachments have been reported to occur in as many as 40% of cases. They arise from
vortex vein obstruction. Most cases can be followed without drainage.
Cystoid macular edema arises from the inflammatory response to the surgical trauma. Its
incidence is reported to be around 25% of cases. Its treatment is based on the anti-inflammatory action of
corticosteroids and nonsteroidal anti-inflammatory agents.
Strabismus following scleral buckling occurs in as many as 50% of cases. It is more common after
reoperations. Most cases resolve spontaneously. However, as many as 25% have long-standing diplopia.
The main cause is restrictive strabismus. This may be corrected with prisms, botulinum toxin injections, or
surgery with adjustable sutures.
Macular pucker has been reported in as many as 17% of cases. In some cases, a PPV with
membrane peel may be indicated.
PVR is the most common cause for surgical failure. In this condition, membranes form on the
surface of the retina and in the vitreous cavity. The membranes are composed of cells derived from the
RPE, glia, and fibrocytes. The membranes contract and lead to tractional retinal detachment. Risk factors

include the number and size of the retinal breaks, the number of previous operations, and the degree of
breakdown of the blood-ocular barrier.
Persistent subclinical subfoveal fluid has been reported to be present in up to 45% of eyes after
successful retinal reattachment with scleral buckling at 6 months and 11% at 12 months. [14] An intravitreal
injection of 0.3 mL of SF6 can displace the fluid out of the subfoveal space into the subretinal periphery
allowing a quicker visual rehabilitation. [15]

Vitrectomy
Initially, PPV was reserved for complicated retinal detachments, such as giant retinal tears, PVR, and
diabetic tractional detachments. Currently, a number of surgeons use it to treat primary uncomplicated
retinal detachments.
Most surgeons use a 3-port approach. If axial opacities (eg, lens fragments, vitreous hemorrhage) are
present, they are removed.
A central core vitrectomy and removal of the vitreous from the margins of the breaks is the next step.
In a phakic eye, PPV causes a higher incidence of cataract formation than scleral buckling, thus care must
be exercised in these maneuvers to prevent accidental damage to the lens. Because of the difficulties in
completely relieving vitreoretinal traction without injuring the lens in phakic eyes, some have proposed that
vitrectomy is the ideal procedure in pseudophakic and aphakic eyes with RRD.
Drainage of subretinal fluid through a break or through a posterior drainage retinotomy is performed during
fluid-air exchange.
Treatment of retinal breaks may be completed with cryotherapy prior to vitrectomy or with laser after the
retina is attached. However, post-reattachment retinopexy is probably safer and performed more widely
than cryotherapy before reattachment.
On occasion, retinal breaks remain unidentified and thus doom the results of the surgical procedure.
Jackson and colleagues have described a new technique for identifying these breaks. [16] This technique
involves injection of trypan blue into the subretinal space with subsequent perfluorocarbon liquid assisted
extrusion of the dye through the occult breaks.
Intraocular tamponade with either long-acting gas or silicone oil is chosen according to the surgeon's
preference. The advantages of gas are that it has a higher surface tension than silicone oil and it
disappears on its own. The disadvantage is that it expands with changing atmospheric pressure. Patients
with an intraocular gas bubble should not fly. On the hand, silicone oil allows patients to fly but needs to be
removed in a second procedure.
The ideal candidates appear to be those with pseudophakia or aphakia or those with phakic eyes with
posterior breaks.
Older series by Escoffery et al, Gartry et al, Hakin et al, and Oshima et al report a slightly lower primary
reattachment rate than scleral buckling alone.[17, 18, 19, 20]However, one meta-analysis showed that vitrectomy
provided more favorable visual outcomes and a higher reattachment rate than scleral buckling in
pseudophakic eyes with primary rhegmatogenous retinal detachment. [21]
A retrospective multicentric interventional study reviewed 181 consecutive cases of noncomplex
rhegmatogenous retinal detachment who underwent pars plana vitrectomy alone versus pars plana
vitrectomy with the addition of a scleral buckle (encircling band). No statistically significant differences were
found in the single-surgery success rate, final reattachment rate (after several surgeries), or final visual
acuity between the two groups.[22]
Transconjunctival small-gauge vitrectomy has gained popularity in the past few years. 25-gauge
transconjunctival vitrectomy was introduced in 2002. [23] Several potential advantages over traditional 20gauge vitrectomy have been described. These include improved patient comfort, faster wound healing,
decreased inflammation, less conjunctival scarring, and a decrease in surgical time in opening and closing.
[24]
In the beginning, there were certain shortcomings with 25-gauge vitrectomy. These included excessive
flexibility of the instruments, poorer illumination, decreased fluidics, and an increase in wound leakage.
The 23-gauge vitrectomy was developed in response to some of these shortcomings. [25] In general, 23gauge instruments exhibit more rigidity than 25-gauge instruments, which allows performing more
peripheral maneuvers. Initially, both 25- and 23-gauge vitrectomy were mostly used in macular cases.
However, as surgeons became more familiar and acquainted with both systems, more complex cases were
being operated on with transconjunctival small-gauge vitrectomy.

After a review of earlier reports, Heimann concluded that transconjunctival 25- and 23-gauge vitrectomy
does not show any advantage over scleral buckling techniques in phakic eyes or 20-gauge vitrectomy in
pseudophakic eyes. Furthermore, he claimed that transconjunctival 25- and 23-gauge vitrectomy worsens
the outcome and increases the postoperative complication rate. [26]
More recent series suggest otherwise. In a prospective case series of 24 eyes with rhegmatogenous retinal
detachment, 23-gauge transconjunctival vitrectomy provided a 91% anatomic success rate. This case
series included eyes with complicated retinal detachments with multiple retinal breaks, inferior retinal
detachments, giant breaks, concomitant choroidal detachment, vitreous hemorrhage, and secondary
macular holes. Thus, their results compare favorably with those reported in the literature for 20-gauge
vitrectomy.[27]
In another retrospective case series of 42 eyes with retinal detachment, a 93% one operation anatomic
success rate was achieved with transconjunctival 25-gauge vitrectomy.[28] A retrospective study compared
the outcomes between eyes operated with 20-gauge and 25-gauge vitrectomy. The authors found no
significant differences between 25-gauge and 20-gauge vitrectomy in the repair of primary
rhegmatogenous retinal detachment.[29]
Improvements in instrumentation and surgical techniques have made small-gauge transconjunctival
vitrectomy the preferred vitrectomy technique for many vitreoretinal surgeons even in complex vitreoretinal
cases.

Pneumatic retinopexy
Pneumatic retinopexy is an office procedure where an expanding gas bubble is injected intravitreally
through the conjunctiva. The patient is positioned postoperatively to take advantage of the surface tension
of the bubble to flatten the retina against the RPE. This closes the break and allows resorption of the
subretinal fluid; then, a chorioretinal adhesion surrounding the retinal break can be produced by either laser
photocoagulation or cryopexy.
Good candidates are those with single retinal breaks or a group of breaks that do not exceed 1 clock hour
and breaks that are confined to the superior two thirds of the fundus. Eyes with PVR grade B or greater are
usually excluded. Teenagers can also be treated with this technique, and the overall success rate is similar
to that of adults. The success rate is lower in patients with vitreous hemorrhage and detachments greater
than 4.5 clock hours. A single procedure with successful reattachment results in better final visual acuity.[30]
Since the gas bubble expands with changing atmospheric pressure, patients should be warned of the perils
of flying.
Pneumatic retinopexy can be considered a possible primary alternative to scleral buckling; however, the
rates of missed or new retinal breaks are higher in pneumatic retinopexy.
Series by Hilton et al, McAllister et al, and Tornambe et al have reported an anatomical success rate of
80% with a single procedure.[31, 32, 33, 34] When additional surgery is performed, 98% have an anatomical
success rate. In eyes with the macula detached for less than 2 weeks, the postoperative visual acuity is
better than in those treated with conventional scleral buckling.
Reported complications include subretinal gas, delayed subretinal fluid reabsorption, endophthalmitis,
extension of retinal detachment, macular hole formation, PVR, and new retinal breaks.
Lincoff episcleral balloon (Of historical interest only, since they are no longer in the market.)
Good candidates are eyes with single retinal breaks or a group of breaks in a single area. The balloon
consists of a catheter with a balloon tip that is expanded with saline injection. Once the balloon is inflated, a
scleral buckling effect is produced.
A conjunctival incision is made, and the deflated balloon is introduced into the Tenon space. Then, the
balloon is inflated with saline. The balloon is deflated and removed after several days.
The anatomical success rate is about 85% in several series reported by Lincoff et al. [35] Visual results are
comparable to those after successful scleral buckling.
Complications are rare, and the most important one is a shift in the location of the balloon. Corneal
abrasions can be bothersome to the patient.

A recent meta-analysis comparing primary vitrectomy versus scleral buckling for the treatment of RRD
showed that scleral buckling was superior to vitrectomy in phakic eyes with uncomplicated RRD. In
contrast, pars plana vitrectomy was superior in pseudophakic and aphakic eyes with RRD. [36]
In contrast, another meta-analysis reported that there were no significant differences in the proportions of
primary reattachments of phakic eyes. Postoperative visual acuities were better in the scleral buckling
group, probably owing to cataract formation in the vitrectomized eyes. In aphakic and pseudophakic eyes,
the proportions of primary reattachment and postoperative visual acuity did not differ significantly between
scleral buckling and pars plana vitrectomy.[37]

Consultations
Patients with a RRD should be referred to a vitreoretinal specialist immediately.

Activity
Patients with a rhegmatogenous retinal detachment (RRD) should rest as much as possible prior to
surgery. Following surgery, depending on whether an intraocular gas bubble is present, the patient will be
instructed to maintain a certain head position.

Further Outpatient Care

See the list below:

Depending on the presence or absence of an intraocular gas bubble, the patient will be instructed
to maintain a certain head position.

Further Inpatient Care

See the list below:

Currently, most vitreoretinal surgery is performed as an outpatient procedure.

Inpatient & Outpatient Medications

See the list below:

Following surgery, most surgeons elect to place the patient on a topical antibiotic for prophylaxis
for 7-10 days, a cycloplegic agent (eg, atropine 1%) for about 1 month, and a topical steroid (eg,
prednisolone acetate 1%) also for about 1 month. The intraocular pressure is monitored during the
postoperative period and treated as necessary.

Deterrence/Prevention
The principal cause of a rhegmatogenous retinal detachment (RRD) is the formation of a retinal break
following a PVD.
To prevent a RRD from occurring, one could try to find a way to prevent vitreous syneresis or PVD. So far,
no such prevention method is available.
Another strategy would be to relieve vitreoretinal traction. Currently, the only known way to do this is
through surgery (ie, scleral buckle, vitrectomy). However, the risks of these procedures do not justify their
use in the prevention of a RRD.
The third strategy is to create chorioretinal adhesions around retinal breaks and other visible predisposing
lesions. One must take into account whether other risk factors are present (eg, myopia, fellow eye RRD,
family history, previous cataract surgery) and whether the patient is symptomatic. On one hand,
asymptomatic patients with visible lesions (eg, lattice) probably have a very low risk of retinal detachment.
These patients can be observed without treatment. On the other hand, myopic, pseudophakic patients with
a RRD in the fellow eye with visible lesions should be strongly considered for prophylactic treatment.
Whether laser treatment is in fact beneficial in preventing a RRD in fellow eyes is not known. However, the
adverse effects are minimal and the potential benefits are great. One must caution the patient that despite
prophylactic treatment, a retinal tear may still occur. On the other hand, Wilkinson concluded that no
conclusions could be reached about the effectiveness of surgical interventions to prevent retinal
detachment in eyes with asymptomatic retinal breaks and/or lattice degeneration. [38]
Individuals with a RRD have a higher risk of developing a RRD in the fellow eye if it is pseudophakic or has
a more myopic refraction.[39]

Complications
See the list below:

PVR is the most common reason for surgical failure.

Rubeosis iridis

Prognosis
Retinal reattachment surgery has improved over the past few decades. Currently, as many as 95% of
patients can have an anatomical success. Visual prognosis depends on whether the macula is attached at
the time of surgery. Once the macula is detached, the photoreceptors start to degenerate, impairing the
visual recovery. Several factors affect the visual prognosis of a macula off detachment. The most important
factor affecting postoperative visual acuity is the preoperative visual acuity.[40]
Persistent subfoveal fluid and increased preoperative foveal thickness are associated with a worse visual
prognosis in macula-off RRD.[41] One report states that a macula off detachment can be operated within the
first 3 days after presentation without compromising the patient's visual prognosis. [42] It is believed that only
50% of patients reach a visual acuity of 20/50 or better. The height of the macula appears to also play a
role in the postoperative visual acuity. Shallow macular detachments were associated with a better visual
outcome.[43]
In a retrospective longitudinal cohort analysis of 9216 Medicare beneficiaries diagnosed with a
rhegmatogenous retinal detachment between 1991-2007, patients who had undergone primary pneumatic
retinopexy were 3 times more likely to receive a second retinal detachment operation compared to scleral
buckling or pars plana vitrectomy. Risk of additional retinal detachment surgery did not differ significantly
between scleral buckling and pars plana vitrectomy. Patients who had a pars plana vitrectomy were 2 times
more likely to suffer adverse events as compared to those who had scleral buckling. [44]
Spectral-domain optical coherence tomography may be used to predict the visual outcome after successful
RRD repair. The status of the external limiting membrane, ellipsoid, and the outer nuclear layer are
important determinants of postoperative visual acuity.[45]

Patient Education
See the list below:

Warn patients who experience a retinal detachment of the potential risk to the fellow eye. In phakic
eyes, the risk is estimated to be 10-15%. In aphakic or pseudophakic eyes, the risk increases to 25-40%.
Instruct patients to seek attention immediately if they start experiencing floaters and/or photopsias.