How to optimally treat rhegmatogenous retinal detachment

Surgeons may safely delay operating on rhegmatogenous retinal detachment (RRD) for a few days to accommodate their schedules, a new study suggested.

The risk of macular detachment was only 0.7% when surgery was delayed up to 72 hours in a series patients put on strict bed rest after diagnosis, wrote Javad Nouri Hajari, MD, of the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.

“This enables the surgery to be scheduled for the next day, where the surgeon will be better suited for conducting microsurgery because the surgeon would be rested,” he wrote.

Dr. Hajari reported the finding in his doctoral thesis, which appears in Acta Ophthalmologica, and earlier in British Journal of Ophthalmology.

The patients who have the best vision before surgery for RRD are the most likely to have good vision after surgery, Dr. Hajari reported.

This is because their fovea has not yet been affected by the detachment, which begins at the periphery and works its way to the centre.

Previous researchers have estimated that the risk of the detachment reaching the fovea ranges from 0.5%-3.7%.

Potential bias

However, these papers based the status of the fovea on charts or retinal drawings done by the examiner, with potential observer bias, he wrote.

Dr. Hajari and four colleagues at Glostrup Hospital in Glostrup, Denmark sought a more definitive finding by following patients presenting with acute symptomatic primary foveola-on RRD over a 32-month period.

They enrolled 96 eyes, of which 50 were eligible for quantitative measurement of the movement of the detachment by optical coherence tomography.

They only documented progression from foveola-on to foveol-off in one eye. In seven others, the detachment was stable during admission.

In the remainder, the researchers noted episodes of progression and regression, with 18% of the detachments showing a net movement toward the foveola. The amount of time since admission appeared to significantly increase the risk of progression.

In another paper included in the thesis, first published in Acta Ophthalmologica, Dr. Hajari and his colleagues studied he Danish National Patient Registry of all Danish citizens in order to identify surgery for RRD conducted in Denmark from Jan. 1, 2001 to Dec. 31, 2009.

They found a total of 6522 cases, of which 22% received reoperation for a redetachment. They calculated that the risk of redetachment was equal to or less than the risk of detachment in the fellow eye within a year from the surgery.

The same was true for surgery techniques using silicone up to 1.5 years after surgery. They also found that in Denmark the need for redetachment surgery has decreased over time, and that high-volume departments have better outcomes than smaller ones.

For the third paper included in the thesis, first published in Retina, Dr. Hajari and his colleagues looked at RRD surgeries from January 2000 to July 2011.

They found 11,451 cases of RRD in the study period, of which 8,553 eyes in 8,081 patients were identified as having primary RRD, for an annual incidence of 13.7 per 100,000 citizens.

Increased RRD attributed to...

They noted a significant increase in the number of cases with RRD during the study period, and attributed it to an increase in cataract surgeries.

Out of 7,941 patients with primary RRD on one eye and no other previous eye disease, 471 developed an additional RRD in the fellow eye, for an overall incidence of 1.3 % per year. They identified male gender, surgery on the lens, and young age as significant risk factors (P < 0.0001).

From this finding, they determined that patients with RRD in the first eye have a 100 times greater risk of developing an RRD in the second eye compared to people without RRD.

Since RRD is a rare disease, treatment can be centralized, the researchers argued.

Based on this finding, they recommended that patients with RRD in the first eye be monitored regularly for at least 10 years.

They also recommended that middle-aged male patients should be monitored closely and be made aware of the large risk of bilateral RRD.

Ideally, clinicians would prevent RRD rather than treating it. Previous studies have found some risk factors for the condition.

Still, screening poses a challenge, the researchers reported. Most patients do not know symptoms, and flashes and floaters do not necessarily indicate retinal tears or detachments, Dr. Hajari reported.

New imaging modalities enable wide-field examination of the fundus, making it possible to screen for the condition to some extent, but it is not clear how effective this approach might be, he concluded.