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Learning goals
After reading this article, the reader should be able to:
● Interpret the possible symptoms of retinal detach-
ment
● Name the treatment options
● Observe the rules of aftercare and recognize the
typical postoperative features.
Incidence Myopia
The incidence of rhegmatogenous retinal detach- Shortsightedness of up to –3 diopters (D)
ment in the general population in Europe is ca. 1 quadruples the risk of retinal detachment, and
in 10 000, corresponding to around 8000 new myopia of more than –3 D increases the danger of
cases each year in Germany. The danger is detachment tenfold.
greatest in the age range 55 to 70 years.
a Trauma
The sudden acceleration of the vitreous body in blunt
Figure 2a: Macroscopic view of an eyeball opened at both sides. C, ocular trauma may lead to extensive tearing of the
Cornea; V vitreous body; E, equator; *, lens (loss of translucency due retina around the base of the vitreous far out in the
to fixation process); arrows: margin of anteriorly displaced vitreous periphery; alternatively, small holes may arise in the
(source: Prof. Peter Meyer, Kantonsspital Basel, Switzerland) fundus of the eye. The rate of traumatic retinal detach-
ment is comparatively low, at 0.2/10 000 (2).
Ophthalmologists are often asked whether pregnant
women with myopia or retinal detachment can be
advised to give birth naturally or whether a cesarean
section would be preferable. There is now a clear
answer to this question: Provided the retina is currently
attached, neither shortsightedness nor a history of rheg-
matogenous retinal detachment speaks against natural
childbirth (9, e18).
A subject of ongoing investigation is whether oral
intake of fluoroquinolones (particularly ciprofloxacin)
leads to increased incidence of retinal detachment. In a
Canadian database study, the rate of detachment during
drug intake was 5 times higher than in a control group
(10). Over the course of the 8-year observation period
(from 2000 to 2007), a cohort of almost a million
persons was evaluated. A total of 4384 experienced a
retinal detachment during this time. The proportion of
b persons who had taken fluoroquinolones was 3.3% in
the detachment group versus 0.6% in the control group
Figure 2b: Macroscopic view of an eye with vitreous traction on the
retina that has not produced a retinal hole. White arrow: vitreous (n = 43 840). This possible effect is explained by accel-
traction strand; black arrow: point of adhesion of vitreous to retina; erated vitreous liquefaction with subsequent retinal
*, retinal vessel (source: Prof. Peter Meyer, Kantonsspital Basel, tearing. No prospective studies on this topic have
Switzerland). been published. To date, the data do not justify a
Vitrectomy
Vitrectomy begins with the removal of the vitreous
humor causing the retinal detachment, followed by dis-
placement of the subretinal fluid by means of a heavy
tamponade (perfluorodecalin or perfluorocarbon) and
scarring of the retina by laser coagulation or cryo-
coagulation. The vitreous is then replaced by a tampon-
ade (Figure 6), which holds the retina against the
underlying retinal pigment epithelium until a firm scar
has formed around the retinal hole. A mixture of air and
gas or a silicone oil tamponade can be chosen for this
purpose. The air/gas mixture is usually chosen in
simpler situations (e.g., when the hole is at the top of
the eyeball). The advantage of the air/gas tamponade is
that it is absorbed and thus does not require removal.
The disadvantage is that the mixture expands postoper-
Figure 4: Retinal detachment with two U-shaped holes. H, Retinal
atively (due to warming and uptake of nitrogen from
hole; F, covering flap; *, bridging artery stabilizing the flap at its
apex; arrows, hole margins the blood), with the danger of pressure decompen-
sation, so the patient should avoid changes in alti-
tude—not only flights but also mountain crossings.
Furthermore, air/gas mixtures result in a massive
are available from recent prospective randomized clini- change in refraction of ca. –50 D (e36). The gases most
cal trials. frequently used are sulfur hexafluoride (SF6), per-
fluoroethane (C2F6), and perfluoropropane (C3F8).
Scleral buckling How long the gas remains in the eye depends on which
After precise localization of all retinal breaks and gas is chosen, how much of it is injected, and on the in-
marking of the sclera, the holes are treated with cryo- traocular pressure. On average the gases remain in the
pexy for scar induction. The traction exerted on the eye for between 14 days (SF6) and 2 months (C3F8)
holes by the vitreous body is then reduced by a foam (19, e37).
sponge sutured to the sclera (14) (Figure 5). In complicated situations silicone oil can be used as
In certain configurations of retinal holes or in the tamponade. The advantage of oil is that the tamponade
presence of multiple breaks, a silicone band can be placed is stable, without expansion, while the disadvantage is
around the whole eyeball; this is known as encircling the necessity for surgical removal. Moreover, oil causes
band. When the buckling has abolished the traction effect a change in refraction of around +6 D, leading to
on the holes, the retinal pigment epithelium absorbs the blurred vision. Reattachment rates of 85% to 90% are
subretinal fluid and the retina becomes reattached in the also reported for vitrectomy (1, 5, 11, 13, 16, 17, 20,
space of a few days. Depending on the situation, a single e30–e32). The frequent complications are cataract in
scleral buckling procedure achieves reattachment rates the first year after surgery (77% [13]) and unintentional
of ca. 85% to 90% (11, 13, 15–17, e30–e32). A frequent creation of retinal holes during surgery (up to 17%
complication of scleral buckling procedures is [21]). Rare complications include bleeding into the
deformation of the eyeball with changes in refraction. In vitreous humor, in around 1% of cases (22), and inflam-
practice this is a problem only with cerclage, hardly ever mation of the inner eye, even endophthalmitis, although
occurring with a sponge (e33, e34). Double vision and eye the latter is very rare indeed (<0.01%) (22). The techni-
movement problems are each reported in around 15% of cal advances in minimally invasive trocar-guided
cases early after operation (18). Occasionally the sponge vitrectomy (Figure 6) have had no effect on the
becomes infected (0.3% [e35]) or migrates into the eyeball endophthalmitis rate (e38–e40), but have reduced the
(<0.01% [14]). In the vast majority of cases the symptoms rate of iatrogenic retinal holes by a factor of 4 (21, e41).
recede after a few days or weeks, so that neither sponges Nevertheless, the classic method continues to be used
nor cerclages are removed. in parallel with the minimally invasive technique
TABLE
The principal anatomical and functional parameters of the prospective randomized trials published to date. Divided according to lens status
Author Number Surgical Follow-up Primary attachment Final attachment Vision stabilized or Postoperative PVR
Year of patients procedure (months) rate (vitrectomy/ rate (vitrectomy/ improved (vitrectomy/ (vitrectomy/ buckling
Design (n) (vitrectomy/ buckling in% [p]) buckling in% [p]) buckling in% [p]) in% [p])
buckling)
Lens status: phakic
Azad (36)
2007 61 30/31 6 80/81 [0.95] 100/100 97/94 [0.57] 10/0 [0.07]
RCT
Koriyama (37)
2007 46 23/23 36 91/91 [1.0] 100/100 100/91 [0.15] 9/4 [0.55]
RCT
Heimann (13)
2007 415 207/209 12 64/64 [0.99] 97/97 [0.98] 75/88 [0.001]* 16/12 [0.25]
RCT
Lens status: pseudophakic/aphakic
Ahmadieh (28)
2005 225 99/126 6 63/68 [0.38] 92/85 [0.11] 65/67 [0.75] 35/29 [0.34]
RCT
Sharma (38)
2005 50 25/25 6 84/76 [0.48] 100/100 96/96 [1.0] 4/20 [0.08]
RCT
Brazitikos (29)
2005 150 75/75 12 95/83 [0.02]** 99/95 [0.17] 97/95 [0.41] 4/5.3 [0.7]
RCT
Heimann (13)
2007 265 132/133 12 72/53 [0.002]** 96/93 [0.43] 86/81 [0.26] 15/23 [0.12]
RCT
The principal anatomical and functional parameters of published prospective randomized studies according to Sun et al. (31).
Top: phakic patients; bottom: pseudophakic/aphakic patients.
Blue (*): significant difference in favor of buckling procedures; red (**) significant difference in favor of vitrectomy.
RCT = randomized controlled trial; PVR = proliferative vitreoretinopathy
(e56, e57). Many different parameters play a part: A de- for the detachment, thus facilitating surgical interven-
tachment in the upper half of the eye with a large tion (e57). If the macula is already detached, an
U-shaped hole typically behaves more aggressively operation in the next few days can be arranged (40).
than a detachment in the lower hemisphere with small
holes and a largely attached vitreous, as is often found,
for example, in young shortsighted patients. Recent Perspective
studies indicate that the surgical management of retinal With the aim of further improving the operative man-
detachment can be planned according to the individual agement of retinal detachment, an ongoing multicenter
situation (e.g., anticoagulation), considering that prospective randomized trial at German retinal surgery
emergency management is associated with a higher rate centers, supported by a competence network for
of complications (39, 40, e57). In many cases flattening clinical studies in retinology (retina.net; in German), is
of the detached retina can be achieved by strict posi- investigating whether a combination of scleral buckling
tioning of the patient on the side of the hole responsible procedures and vitrectomy can yield a better outcome
than vitrectomy alone in the difficult group of patients 15. De la Rúa ER, Pastor JC, Fernández I, Sanabria MR, García-Arumí J,
with retinal detachment following cataract surgery. The Martínez-Castillo V, et al.: Non-complicated retinal detachment
management: variations in 4 years. Retina 1 project; report 1. Br J
first results are expected in 2014. Ophthalmol 2008; 92: 523–5.
16. Pastor JC, Fernandez I, Rodriguez de la Rua E, Coco R, Sanabria-
Conflict of interest statement Ruiz Colmenares MR, Sanchez-Chicharro D, et al.: Surgical out-
The authors declare that no conflict of interest exists. comes for primary rhegmatogenous retinal detachments in phakic
and pseudophakic patients: the Retina 1 Project-report 2. The
Manuscript received on 3 June 2013, revised version accepted on
British Journal of Ophthalmology 2008; 92: 378–82.
9 September 2013. 17. Haritoglou C, Brandlhuber U, Kampik A, Priglinger SG: Anatomic
success of scleral buckling for rhegmatogenous retinal detach-
ment-a retrospective study of 524 cases. Int J Ophthalmol 2010;
Translated from the original German by David Roseveare.
224: 312–8.
18. Framme C, Roider J, Hoerauf H, Laqua H: Komplikationen nach
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and clinical associations. Br J Ophthalmol 2010; 94: 678–84. et al.: Primary vitrectomy for rhegmatogenous retinal detachment:
3. Mitry D, Singh J, Yorston D, Siddiqui MAR, Wright A, Fleck BW, et al.: an analysis of 512 cases. Graefes Arch Clin Exp Ophthalmol 2006;
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5. Feltgen N, Weiss C, Wolf S, Ottenberg D, Heimann H: Scleral buckling 22. Heussen N, Hilgers RD, Heimann H, Collins L, Grisanti S: Scleral
versus primary vitrectomy in rhegmatogenous retinal detachment buckling versus primary vitrectomy in rhegmatogenous retinal de-
study (SPR Study): recruitment list evaluation. Study report no. 2. tachment study (SPR study): multiple-event analysis of risk factors
Graefes Arch Clin Exp Ophthalmol 2007; 245: 803–9. for reoperations. SPR Study report no. 4. Acta Ophthalmol (Copenh)
6. Mitry D, Chalmers J, Anderson K, Williams L, Fleck BW, Wright A, et 2011; 89: 622–8.
al.: Temporal trends in retinal detachment incidence in Scotland be- 23. Byer NE: Subclinical retinal detachment resulting from asymp-
tween 1987 and 2006. Br J Ophthalmol 2011; 95: 365–9. tomatic retinal breaks: prognosis for progression and regression.
7. Herrmann W, Helbig H, Heimann H: Pseudophakieablatio. Klin Ophthalmology 2001; 108: 1499–503; discussion 1503–4.
Monatsblätter Für Augenheilkd 2011; 228: 195–200.
24. Mitry D, Awan MA, Borooah S, Siddiqui MAR, Brogan K, Fleck BW,
8. Wolfram C, Pfeiffer N: Weißbuch zur Situation der ophthalmol- et al.: Surgical outcome and risk stratification for primary retinal
ogischen Versorgung in Deutschland. 2012th ed. München 2012. detachment repair: results from the Scottish Retinal Detachment
9. Hart NC, Jünemann AGM, Siemer J, Meurer B, Goecke TW, Schild study. Br J Ophthalmol 2012; 96: 730–4.
RL: Geburtsmodus bei präexistenten Augenerkrankungen. Z Für Ge- 25. Heimann H: Netzhautablösung: Therapeutisches Vorgehen. Augen-
burtshilfe Neonatol 2007; 211: 139–41. heilkunde up2date 2012: 243–59
10. Etminan M, Forooghian F, Brophy JM, Bird ST, Maberley D: Oral flu-
26. Arya AV, Emerson JW, Engelbert M, Hagedorn CL, Adelman RA:
oroquinolones and the risk of retinal detachment. JAMA 2012; 307:
1414–9. Surgical management of pseudophakic retinal detachments: a
meta-analysis. Ophthalmology 2006; 113: 1724–33.
11. D’Amico DJ: Clinical practice. Primary retinal detachment. N Engl J
Med 2008; 359: 2346–54. 27. Ho JD, Liou SW, Tsai CY, Tsai RJF, Lin HC: Trends and outcomes of
treatment for primary rhegmatogenous retinal detachment: a 9-year
12. Feltgen N, Heimann H, Hoerauf H, Walter P, Hilgers RD, Heussen N: nationwide population-based study. Eye Lond Engl 2009; 23:
Scleral buckling versus primary vitrectomy in rhegmatogenous reti-
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nal detachment study (SPR study): Risk assessment of anatomical
outcome. SPR study report no. 7. Acta Ophthalmol 2013; 91: 28. Ahmadieh H, Moradian S, Faghihi H, Parvaresh MM, Ghanbari H,
282–7. Mehryar M, et al.: Anatomic and visual outcomes of scleral buckling
13. Heimann H, Bartz-Schmidt KU, Bornfeld N, Weiss C, Hilgers RD, versus primary vitrectomy in pseudophakic and aphakic retinal de-
Foerster MH: Scleral buckling versus primary vitrectomy in rhegma- tachment: six-month follow-up results of a single operation-report
togenous retinal detachment: a prospective randomized multicenter no. 1. Ophthalmology 2005; 112: 1421–9.
clinical study. Ophthalmology 2007; 114: 2142–54. 29. Brazitikos PD, Androudi S, Christen WG, Stangos NT: Primary pars
14. Hoerauf H, Heimann H, Hansen L, Laqua H: Skleraeindellende Abla- plana vitrectomy versus scleral buckle surgery for the treatment of
tiochirurgie und pneumatische Retinopexie. Techniken, Indikationen pseudophakic retinal detachment: a randomized clinical trial. Retina
und Ergebnisse. Ophthalmologe 2008; 105: 7–18. 2005; 25: 957–64.
30. Adelman RA, Parnes AJ, Ducournau D: Strategy for the Manage- 37. Koriyama M, Nishimura T, Matsubara T, Taomoto M, Takahashi K,
ment of Uncomplicated Retinal Detachments: The European Vitreo- Matsumura M: Prospective study comparing the effectiveness of
Retinal Society Retinal Detachment Study Report 1. Ophthalmology scleral buckling to vitreous surgery for rhegmatogenous retinal
2013; 120: 1804–8. detachment. Jpn J Ophthalmol 2007; 51: 360–7.
31. Sun Q, Sun T, Xu Y, Yang X-L, Xu X, Wang BS, et al.: Primary vitrec- 38. Sharma YR, Karunanithi S, Azad RV, Vohra R, Pal N, Singh DV, et al.:
tomy versus scleral buckling for the treatment of rhegmatogenous Functional and anatomic outcome of scleral buckling versus
retinal detachment: a meta-analysis of randomized controlled clini- primary vitrectomy in pseudophakic retinal detachment. Acta
cal trials. Curr Eye Res 2012; 37: 492–9. Ophthalmol Scand 2005; 83: 293–7.
32. Thelen U, Amler S, Osada N, Gerding H: Outcome of surgery after 39. Diederen RMH, La Heij EC, Kessels AGH, Goezinne F, Liem ATA,
macula-off retinal detachment – results from MUSTARD, one of the Hendrikse F: Scleral buckling surgery after macula-off retinal de-
largest databases on buckling surgery in Europe. Results from a tachment: worse visual outcome after more than 6 days.
large German case series. Acta Ophthalmol 2012; 90: 481–6. Ophthalmology 2007; 114: 705–9.
33. Kreissig I: View 1: Minimal segmental buckling without drainage. Br 40. Henrich PB, Priglinger S, Klaessen D, Kono-Kono JO, Maier M,
J Ophthalmol 2003; 87: 782–4. Schötzau A, et al.: Macula-off Ablatio retinae – eine Zeitfrage? Klin
34. Heussen N, Feltgen N, Walter P, Hoerauf H, Hilgers RD, Heimann H: Monatsblätter Für Augenheilkd 2009; 226: 289–93.
Scleral buckling versus primary vitrectomy in rhegmatogenous reti-
nal detachment study (SPR Study): predictive factors for functional
outcome. Study report no. 6. Graefes Arch Clin Exp Ophthalmol Corresponding author
2011; 249: 1129–36. Prof. Dr. med. Nicolas Feltgen
Universitäts-Augenklinik
35. Heimann H, Hellmich M, Bornfeld N, Bartz-Schmidt KU, Hilgers RD, Robert-Koch-Str. 40
Foerster MH: Scleral buckling versus primary vitrectomy in rhegma- 37075 Göttingen, Germany
togenous retinal detachment (SPR Study): design issues and impli- [email protected]
cations. SPR Study report no. 1. Graefes Arch Clin Exp Ophthalmol
2001; 239: 567–74.
36. Azad RV, Chanana B, Sharma YR, Vohra R: Primary vitrectomy
versus conventional retinal detachment surgery in phakic rhegma-
togenous retinal detachment. Acta Ophthalmologica 2007; 85:
540–5. @ For eReferences please refer to:
www.aerzteblatt-international.de/ref0114
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Question 1 Question 6
What is the incidence of rhegmatogenous retinal What symptoms may point to impending retinal
detachment in the general population? detachment?
a) 1/1 000 000 a) Flashes of light and “smoke signals”
b) 1/100 000 b) Pain
c) 1/10 000 c) Vertigo
d) 1/1 000 d) Double vision
e) 1/100 e) Distorted vision
Question 2 Question 7
At what age do patients typically suffer a How is retinal detachment usually diagnosed?
rhegmatogenous retinal detachment? a) Computed tomography
a) 15 to 30 years b) High-resolution magnetic resonance imaging
b) 35 to 50 years c) Funduscopy
c) 55 to 70 years d) Skull X-ray
d) 75 to 90 years e) Optical coherence tomography
e) 95 to 105 years
Question 8
What is the typical treatment after diagnosis of
Question 3
rhegmatogenous retinal detachment?
What is the principal cause of rhegmatogenous
a) Observation and monitoring
retinal detachment?
b) Lateral positioning of the head and rest
a) Glaucoma
c) Exercise therapy and reading
b) Posterior vitreous detachment
d) Scleral buckling procedures and/or vitrectomy
c) Cataract
e) Systemic administration of fluoroquinolones
d) Corneal clouding
e) Pregnancy
Question 9
What is most likely to lead to early detection of a retinal
Question 4 detachment?
What is the most common ophthalmologic risk a) Monthly ophthalmologic examination
factor? b) Three-monthly ophthalmologic examination
a) Myopia c) Prophylactic lasering of all retinal degenerations
b) Herpes dendritica d) Regular wearing of visual aids (glasses, contact lenses)
c) Keratoconus e) Information of the patient about the symptoms of retinal
d) Iritis detachment
e) Retinal perfusion disorder
Question 10
Question 5 What is the mean visual acuity after rhegmatogenous retinal
What is the most frequent risk factor if one eye detachment with macular involvement (on the standard
is already affected? decimal scale, where 1.0 represents the mean full acuity)?
a) Amyloidosis a) Blindness to 0.1
b) Viral infection b) 0.1 to 0.2
c) Herpes zoster c) 0.3 to 0.4
d) Fibromyalgia rheumatica d) 0.6 to 0.8
e) Known retinal detachment in the other eye e) 1.0
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