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      Drugs & Diseases > Ophthalmology

      Postoperative Retinal Detachment

      Updated: Apr 03, 2023
      • Author: Lihteh Wu, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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      Overview

      Background

      Anytime subretinal fluid accumulates in the space between the neurosensory retina and the underlying retinal pigment epithelium (RPE), a retinal detachment occurs. Depending on the mechanism of subretinal fluid accumulation, retinal detachments traditionally have been classified into rhegmatogenous, tractional, and exudative.

      The term rhegmatogenous is derived from the Greek word rhegma, which means a discontinuity or a break. A rhegmatogenous retinal detachment (RRD) occurs when a tear in the retina leads to fluid accumulation with a separation of the neurosensory retina from the underlying RPE. This is the most common type of retinal detachment.

      Intraocular surgery is a major risk factor in the development of RRD. Since cataract surgery is the most common intraocular procedure, it also is the most common risk factor for RRD. It has been estimated that 20-40% of RRDs occur in eyes that have undergone cataract extraction.The incidence  of RRD in pseudophakic eyes ranges from 0.6% to 1.7%. [1, 2, 3] Intraocular lens exchanges have become more common recently. A recent series of almost 200 patients from a tertiary center from Iran showed that 4.1% of eyes developed a RRD. Patients were followed for a mean of 15.7 months. [4]  

       

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      Pathophysiology

      Vitreoretinal traction is responsible for the occurrence of RRD. As the vitreous becomes more syneretic (liquefied) with age, a posterior vitreous detachment (PVD) occurs. In most eyes, the vitreous gel separates from the retina without any sequelae. However, in certain eyes, strong vitreoretinal adhesions are present, and the occurrence of PVD can lead to a retinal tear formation. Fluid from the liquefied vitreous can seep under the tear, leading to a retinal detachment.

      Aphakia and pseudophakia, especially after YAG capsulotomy, predispose to PVD. Previous studies have shown that the incidence of PVD increased with age and with duration of the aphakia. A significant increase was reported after 1 year of aphakia. Clinical studies reported almost a 100% prevalence of PVD in aphakic eyes. In a postmortem study, 84% of eyes with intracapsular cataract extraction had PVD. Of eyes with extracapsular cataract extraction and posterior capsulotomy, 76% had PVD. Of eyes with extracapsular cataract extraction with an intact posterior capsule, 40% had PVD. It is this increased incidence of PVD that is a risk factor in the development of retinal breaks and subsequent RRD.

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      Epidemiology

      Frequency

      United States

      The incidence of RRD following uncomplicated cataract extraction has been reported to be 0-3%. Most series report that about 50% of RRD occurs during the first year following cataract surgery. [5] Recent studies have shown that even though the risk for pseudophakic retinal detachment is highest during the first year after cataract surgery, the increased risk continues for at least 11 years. [6, 7]

      The incidence of RRD following penetrating keratoplasty (PKP) depends on whether the eye is phakic or pseudophakic and if the vitreous was manipulated. Several series report 2.4-6.8% of cases with RRD. [8, 9, 10]

      Up to 3% of eyes undergoing pars plana vitrectomy (PPV) for nonclearing vitreous hemorrhage and 5% of eyes undergoing PPV for a macular pucker will develop RRD. In 55% of cases, the RRD appeared during the first 4 weeks. [11, 12, 13, 14, 15]

      In a series of 765 patients undergoing strabismus surgery, 0.4% experienced an inadvertent retinal perforation, but none developed RRD. [16]

      International

      A 6-year retrospective review based on medical records and insurance claims from the Taiwan Bureau of National Health Insurance, revealed a cumulative 6-year rate of pseudophakic retinal detachment of 1.16%. [17]

      A 5-year cataract surgery audit from the Singapore National Eye Centre revealed that 1.3% of over 48,000 cases of phacoemulsification were complicated by a rhegmatogenous retinal detachment. [18]

      A large register-based cohort study of more than 200,000 Danish patients that underwent uncomplicated phacoemulsification showed that there is a 4-fold increase in risk of developing a retinal detachment following cataract surgery. [7]

      A 2015 retrospective case series from an Irish population reported a retinal detachment incidence of 5.9% following implantation of Boston type I and II keratoprosthesis. [19]

      In a large series from Saudi Arabia, the incidence of inadvertent globe perforation in strabismus surgery was 3 in 1000 with 1 eye developing a RRD. [20]

      A recent study from Norway found that there was a substantial increase in the incidence of RRD in the Norwegian population, particularly in those patients with a prior intraocular lens. [21]

      Mortality/Morbidity

      Some earlier reports have emphasized the poorer outcome of RRD in pseudophakic eyes as compared to phakic eyes. Peripheral capsular opacification, lenticular remnants, and optical effects induced by the rim of the intraocular lens (IOL) may impair visualization of the small peripheral retinal breaks by indirect ophthalmoscopy, leading to missed breaks during surgical repair. However, most reports have shown similar results in the repair of primary phakic RRD compared to primary pseudophakic or aphakic RRD.

      Sex

      Postoperative RRD appears to be more common in men than in women. The 6-year cumulative pseudophakic retinal detachment rate was much higher in Taiwanese males (1.90%) than females (0.56%). [17] When the fellow unoperated eye was used as a reference, sex did not modify the risk of developing a pseudophakic retinal detachment. [7]

      Age

      Since previous cataract surgery is a risk factor for the development of a retinal detachment, patients at risk tend to be those aged 50-90 years.

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      Prognosis

      A recent study from Spain emphasized the poorer outcome of rhegmatogenous retinal detachments in pseudophakic eyes when compared to phakic eyes. [22]

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      Clinical Presentation
       
       
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