Approach
Treatment should aim to close the break and counter or eliminate the traction leading to its formation, irrespective of the patient's age or the presence or absence of risk factors.[48]
Refer early for specialist intervention by an appropriately trained ophthalmologist or according to local guidance.[37]
Treatment for RD depends on the type of detachment and the underlying etiology.
Timing of treatment
Earlier reattachment of a rhegmatogenous retinal detachment (RD) increases the likelihood of complete functional improvement.
Aim to complete macula-on RDs within one day and macula-off RDs within a few days to one week. One meta-analysis of observational studies found that patients with early repair of both macula-on rhegmatogenous RD (≤24 vs. >24 hours) and macula-off RD (0-3 vs. 4-7 days) had better visual outcomes.[49] Delaying surgery also increases the risk of developing PVR.
Patients can tolerate tractional RD for a long time, especially when they do not progress or progress slowly. Prophylactic surgery should be considered if the macula is threatened.
Exudative RDs rarely require acute intervention, unless patients have thick submacular bleeds, for which delay may cause irreversible damage.
Preoperative evaluation
Preoperative evaluation should identify the number, location, and type of break(s); determine the location, type, and degree or severity of vitreoretinal traction; and identify risk factors for postoperative scarring (e.g., PVR), such as vitreous pigment.
In tractional RD, closely monitor progress toward the macula. In hemorrhagic RD, the thickness of any submacular blood informs treatment decisions.
Posterior vitreous detachment (PVD) and retinal breaks without detachment
PVD cannot be monitored with sufficient certainty because posterior vitreoschisis can mask the diagnosis. Prophylactic treatment, such as laser cerclage or vitrectomy, can dramatically reduce the risk of subsequent detachment. Symptoms guide management in patients with retinal breaks and no detachment: monitoring is appropriate if asymptomatic; sealing with cryopexy or laser retinopexy is necessary if symptomatic.
Rhegmatogenous RD
Rhegmatogenous RD is an indication for surgical treatment. Treatment should aim to close the break and counter or eliminate the traction leading to its formation, irrespective of the patient's age or the presence or absence of risk factors.[48] Long-standing detachment or the patient’s general condition may preclude surgery. Some asymptomatic inferior RDs may simply require observation.
Treatment options include:
Scleral buckling + cryopexy/laser
Vitrectomy + cryopexy/laser
Pneumatic retinopexy (using cryopexy/laser).
Scleral buckling and vitrectomy have similar outcomes on several measures when repairing simple rhegmatogenous RD (e.g., primary retinal reattachment rate, postoperative visual acuity, and anatomical success).[50]
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However, more people experience cataract development, cataract progression, and new/iatrogenic breaks with vitrectomy than with scleral buckling, whereas fewer people experience choroidal detachment with vitrectomy.[50]
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Vitrectomy may have better outcomes than scleral buckling in pseudophakic eyes (e.g., primary retinal reattachment and RD recurrence).[50]
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Minimally invasive pneumatic retinopexy is indicated for the repair of uncomplicated rhegmatogenous RD (e.g., small breaks in the superior two-thirds of the fundus).[51] Observational data suggest a success rate between 54% and 77% after a single procedure.[52][53][54] Success is lower in eyes with inferior breaks, marked vitreoretinal traction, and multiple breaks, but may be superior in phakic eyes than in pseudophakic eyes.[55] Failure of pneumatic retinopexy does not appear to impact upon final visual acuity following a subsequent procedure.[52] Pneumatic retinopexy is associated with fewer postoperative complications than scleral buckle, but it has lower reattachment and higher recurrence rates.[56]
Tractional RD
Vitrectomy is considered the most suitable treatment option for significant traction, taking care to avoid creating iatrogenic breaks. A scleral buckle (usually an encircling element) may also be placed as an adjunct to vitrectomy.
Exudative RD
Interventions often focus on the etiology. Inflammatory conditions may require topical and/or systemic corticosteroids; infections may require appropriate antimicrobial therapy; and diabetes requires adequate hypertensive and glycemic control.
In select cases, the subretinal fluid may be drained by retinotomy.
Hemorrhagic RD
In hemorrhagic RD, the thickness of any submacular blood informs decision-making. Delay may lead to irreversible damage.
For submacular hemorrhage, remove or reposition the blood away from the fovea. Blood may be drained or evacuated by retinotomy or retinal inversion (for large clots). Alternatively, tissue plasminogen activator (tPA) and a gas bubble may be injected and the patient positioned to "push" the blood out from the submacular space into an inferior location where the photoreceptor damage is less noticeable to the patient.
Surgical techniques
Choice of surgery will depend on patient-specific factors, such as the number, location and size of retinal breaks, plus the surgeon’s preference and the presence of any proliferative vitreoretinopathy.
Scleral buckling
Retinal breaks are localized and treated (diathermy, cryotherapy, or laser photocoagulation). A silicone buckling element (sponge, band, tire) alone, or in combination, is sutured to the scleral surface. The configuration of the scleral buckle is influenced by several factors including the types, number and magnitude of the tears.[57] Adjuvant drainage of subretinal fluid may contribute to retinal repair.
Vitrectomy
Performed alone or in combination with a scleral buckle. The vitreous is completely removed, including "shaving" of the vitreous base. The retina is flattened and laser retinopexy performed. Cryopexy may be an alternative. An intraocular tamponade is inserted (typically gas, e.g., SF6 or C3F8; silicone oil may be indicated) to prevent fluid flow into the subretinal space until retinopexy provides a permanent seal.
Pneumatic retinopexy
An outpatient procedure. Pneumatic retinopexy comprises injection of an intravitreal gas or air bubble to tamponade the retinal break(s), followed by laser retinopexy or cryoretinopexy to seal break site(s).[58] Postprocedural posturing ensures sufficient tamponade of retinal breaks. Specific elements of the pneumatic retinopexy are dictated by the retinal pathology and may vary according to surgeon preference.
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