Postoperative Retinal Detachment Clinical Presentation

Updated: Feb 28, 2017
  • Author: Lihteh Wu, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
  • Print
Presentation

History

Since most postoperative retinal detachments are rhegmatogenous in nature, similar symptoms, such as photopsias, floaters, visual field defects, and central visual loss, are experienced by patients.

Next:

Physical

The findings are typical of rhegmatogenous retinal detachment (RRD) with the following special features:

  • The retinal breaks are often small and difficult to visualize.

  • The retinal breaks are often located along the posterior border of the vitreous base.

  • The retinal detachment is often extensive.

  • The macula is commonly involved.

Previous
Next:

Causes

As with all RRDs, vitreous traction is the main culprit.

Cataract extraction

Aphakia and pseudophakia, especially with an open posterior capsule, predispose to PVD.

Preoperative risk factors include myopia, young age, lattice degeneration, and a history of previous RRD in the fellow eye.

The most important intraoperative risk factor is vitreous loss. The cataract extraction technique (ie, extracapsular, intracapsular, phacoemulsification) does not appear to play a role. The placement of an IOL does not seem to play a role. Conflicting reports exist regarding the importance of the type of IOL placed. Some reports claim that anterior chamber intraocular lens (ACIOL) and iris clip lenses induce more inflammation, resulting in a higher incidence of proliferative vitreoretinopathy (PVR).

The most important postoperative factor is YAG capsulotomy.

Postoperative RRD after cataract extraction is more common in previously vitrectomized eyes regardless of the technique used.

In patients with atopic cataracts, the implantation of an IOL in-the-bag might prevent the contraction of the lens capsule and decrease the incidence of postoperative RRD.

Penetrating keratoplasty

Retinal breaks and detachments are rare in phakic eyes that undergo PKP.

RRDs are fairly common in aphakic or pseudophakic eyes that have undergone PKP, especially if an anterior vitrectomy was performed.

Pars plana vitrectomy

PPV may also be complicated by iatrogenic retinal breaks, which, if undetected, may lead to RRD. They commonly occur posterior to the sclerotomy site as a result of mechanical traction by the exchange of instruments through the sclerotomy. Most of these breaks will be detected and treated intraoperatively. The exception occurs during macular hole surgery in which the surgeon creates a PVD as part of the procedure. The iatrogenic breaks are not behind the sclerotomies as expected but tend to be inferior instead.

In patients with retained lens material, higher traction can be induced due to nuclear fragment manipulation. Recommended techniques for these patients include the following: the induction of PVD with maximal vitreous removal before phacofragmentation, lens fragment debulking before fragmentation, use of low energy with high aspiration during the removal of retained lens material, and intraoperative indirect ophthalmoscopic evaluation of the retinal periphery with scleral indentation to diagnose intraoperative retinal breaks.

Small-gauge transconjunctival sutureless vitrectomy has also been reported to cause iatrogenic postoperative RRD. This is thought to be related to the lack of adequate peripheral vitrectomy with the more flexible instruments and excessive traction at the sclerotomy sites. Studies have compared favorably the safety profile of the 23-gauge system to the 25-gauge system. In a recent retrospective case series of macular holes that underwent phacovitrectomy with either 20 or 23 gauge, the incidence of retinal breaks was higher with 20 gauge versus 23 gauge. [17]

Strabismus surgery

Inadvertent globe perforation during strabismus surgery has been reported to cause RRD. [16] However, the incidence appears to be quite low. It is recommended that a high index of suspicion be maintained. If retinal perforation is suspected, indirect ophthalmoscopy should be performed to examine the retina. If necessary, cryotherapy or laser should be performed.

Previous