Management
Prophylactic treatment for conditions that may lead to RD is controversial. As a general rule, it should be undertaken only when the risk of complications from the treatment is lower than the risk of breaks leading to clinical RD. Prophylactic treatment may be suggestive in the following cases: symptomatic retinal breaks, large symptomatic operculated holes (Fig. 7), high-risk fellow eyes of nontraumatic giant retinal breaks, retinal breaks before cataract surgery, breaks and lattice degeneration in the fellow eye of RD, family history of RD, breaks due to trauma, breaks and lattice degeneration in highly myopic eyes. In all these conditions, close monitoring is advised. Current evidence supports prophylactic treatment only for symptomatic tractional tears. Patients undergoing prophylactic treatment should be warned about the possibility of developing a RD despite of the treatment and asked to seek immediate care if symptoms of RD are noted.
Asymptomatic retinal breaks in phakic eyes with lattice degeneration, high myopia, and fellow eye detachments show no significant benefit from prophylactic treatment. It is therefore recommended that patients with peripheral retinal degenerations that are at high risk for developing a RD, be properly educated and instructed to seek ophthalmologic care immediately if suggestive symptoms develop. Laser photocoagulation, cryotherapy and scleral buckling have been used in the prophylaxis of predisposing retinal lesions (in particular, in patients with RRD as a feature of genetic syndromes). The goal of treatment is to create a chorioretinal adhesion surrounding a break so that no communication exists between the vitreous cavity and the subretinal space.
Management for asymptomatic RD varies from conservative observation to surgery.
Symptomatic RD is an indication for surgery and requires immediate specialist referral. Prompt diagnosis and surgical treatment of RD can prevent impending vision loss or can restore vision. ERD usually does not require surgical intervention.
The three principal methods for reattachment of the retina include scleral buckling, vitrectomy (pars plana vitrectomy) and pneumatic retinopexy. In over 90% of cases, RD can be fixed successfully. In the best cases, more than one operation is needed in 10% of cases.
Scleral buckling surgery is the most common operation for RD and considered the “gold standard” for uncomplicated RRD. It aims at restoring the eye wall contact with the detached retina. Successful scleral buckling depends on accurate localization of the retinal breaks (by indirect ophthalmoscopy), induction of permanent chorioretinal adhesion (achieved by diathermy, cryotherapy or photocoagulation) and support of the retinal breaks on the buckle (accomplished with external scleral indentation with donor tissue or synthetic materials; solid silicone rubber or sponges are the most commonly employed buckling elements). A buckle may be affixed in an equatorial or radial orientation, may encircle the eye under the rectus muscles and be tightened like a belt, or may be arrayed in many combinations. The retina is reattached after the encircling scleral buckle has been secured and subretinal fluid has been drained.
In general, primary repair with scleral buckling lasts one to two hours. Repeat surgeries or more complex detachments may take longer. Scleral buckling results in high rates of stable and long-lasting successful reattachment (95% reattachment at 20 years reported). Vision is also preserved or substantially recovered (postoperative visual acuity of 20/50 or better).
Possible postoperative complications (lasting for several days or weeks) include prolonged recovery time, pain, swollen, red, or tender eye, infection, induced refractive error with increased myopia, floaters, strabismus, ocular motility disturbances. In less than 5% of cases, diplopia, cystoid macular edema, eyelid malpositions, retinal breaks, intraocular dislocation of an implanted lens, vitreous and choroidal hemorrhage, loss of vitreous during suturing or drainage, glaucoma, choroidal detachment, cataract formation, late extrusion or infection of the buckle may develop. Retinal vascular occlusion, anterior segment ischemia and endophthalmitis are extremely rare. Recurrent detachment is one of the most important complications after scleral buckling. Failure of reattachment is mainly due to development of proliferative vitreoretinopathy. In these cases, patients typically require further surgical intervention, including vitrectomy.
Vitrectomy is a surgical approach that relieves traction by removing the vitreous attached to the retinal breaks. Artificial vitreous substitutes are used to re-establish intraocular volume and mechanically flatten detached retina. They include gases (air and perfluorocarbon gases) and liquids (silicone oil and perfluorocarbon liquids). The gas gradually disappears during the postoperative period (within 1 to 4 weeks) and is replaced by fluid produced by the eye. Rarely in cases of primary detachment silicone oil is placed in the vitreous cavity and is usually removed from the eye if retina remains attached. With all of these procedures, either laser or cryopexy is used to "weld" the retina back in place. Sometimes a vitrectomy may be combined with a scleral buckle. Vitrectomy avoids some of the complications associated with scleral buckling (diplopia, choroidal detachment, perforation of the sclera, abnormalities in the eyelid, late extrusion and infection of the buckle), but carries higher risks of cataract formation in phakic eyes, glaucoma and new retinal breaks.
Pars plana vitrectomy is a surgical procedure that can be performed under local or general anesthesia in which the access into the eye is done through the pars plana, the section of the eye between the retina and the pars plicata. Pars plana vitrectomy was used in the past as primary surgical intervention only in complicated retinal detachments, such as very large tears, scar tissue on the retina, excessive blood in the vitreous, or detachments that failed by other methods. It is now an increasingly used as primary option for RRD repair and for removal of opacities and synechiae. The main advantage of this surgical procedure over scleral buckling alone is the ability to visualize all retinal breaks by using internal search with the indirect viewing systems and scleral indentation. If breaks are not identified, a higher failure rate may be expected. Using pars plana vitrectomy, high reattachment rates (more than 90% single-procedure attachment rate) and high rate of visual improvemet (visual acuity of 20/50 or better in up to 80% of cases) postoperatively are achieved in pseudophakic eyes, with low intraoperative complications. Most of the healing occurs during the first month, while full visual recovery may take a few months. Disadvantages of pars plana vitrectomy include the need for postoperative positioning, avoidance of airplane travel or traveling to altitude with a gas bubble in the eye, extended recovery time (depending on the type of gas placed). Other possible complications after include lens trauma (10%) and postoperative cataract (nuclear sclerosis) progression (80 to 98% of vitrectomized eyes).
Transconjunctival sutureless vitrectomy using a 25-gauge or 23-gauge incision has been introduced in recent years. This vitreoretinal surgery technique use a thin 25-gauge or 23-gauge, this the incisions left in the sclera after removal of the cannulas are so small that they seal without suturing, thereby minimizing surgically induced trauma, and decreasing the convalescence period, operating time, and postoperative inflammatory response.
Pneumatic retinopexy (an outpatient procedure performed under local anesthesia) is indicated for selected. These include a single retinal break and superior retinal breaks smaller than one clock hour. With this technique, the causative tear(s) are identified and treated via injection of a gas bubble (perfluoropropane or sulfur hexafluoride) into the vitreous space that pushes against the area of the retinal tear(s). Laser or cryo-surgery is used to secure the retina to the eye wall around the retinal tear. With appropriate positioning of the head, retinal breaks are closed by the bubble. Reattachment of the retina occurs through physiologic resorption of subretinal fluid. Gradual elution of gas from the eye leaves the retina reattached, with the retinal breaks permanently closed by the retinopexy scar.
The advantages of pneumatic retinopexy over the other procedures are reduced postoperative morbidity and recovery time. It is less invasive and less costly. However, it is not suitable as a treatment for every detachment owing to practical limitations in the ability to close breaks by head-positioning with an intraocular gas bubble. Contraindications may include inferior breaks, lattice degeneration, media opacities, uncontrolled glaucoma, pseudophakia or aphakia.
Disadvantages of the procedure include the necessity for correct postoperative positioning and close follow-up. In the postoperative period patients should avoid air travel. The most frequent postoperative complications include misplaced gas injection, persistent subretinal fluid or trapped gas, or inferior break that will need a new surgery. Endophthalmitis, macular folds, an increase in intraocular pressure, choroidal detachment, cataracts, epiretinal membranes, vitreous or subretinal hemorrhage are rare.
Despite the variety of surgical techniques, the management of RD remains a challenge. So far, only a few randomized controlled clinical trials compared directly different surgical techniques. Consequently, there are no results that consistently demonstrate the superiority of a single method. The use of combined surgical approaches is also an active area of clinical investigation. Data from case series suggest that primary detachments in phakic eyes with complexity exceeding the original indications for pneumatic retinopexy may be treated successfully with scleral buckling or vitrectomy, whereas vitrectomy appears to be preferable for corresponding detachments in pseudophakic eyes. Further prospective clinical trials are required to address the question as to which procedure is an appropriate therapeutic approach for RD.
Most retinal detachment surgery is successful, although a second operation is sometimes needed. The following factors may predict insufficient anatomical success after surgery: poor presenting vision, longer duration of symptoms before presentation, the presence of preoperative choroidal detachment, vitreous hemorrhage, large retinal breaks (≥ 1 clock hour), breaks located posterior to the equator (Fig. 8). The time between the occurrence of RD and the surgical repair appears to be of major importance for the functional results obtained after surgery.
Management of the fellow eye should take in consideration the data reporting prevalence of RD in the fellow eye at 4.5%, 16.4%, and 35.7% in phakic, pseudophakic, or aphakic eyes, respectively. Prophylactic treatment of retinal tears and lattice degeneration in fellow eyes does not always prevent the development of RD.
