Further Outpatient Care

Depending on the presence or absence of an intraocular gas bubble, the patient will be instructed to maintain a certain head position.

Further Inpatient Care

Most vitreoretinal surgery is performed as an outpatient procedure.

Inpatient & Outpatient Medications

Following surgery, most surgeons elect to place the patient on a topical antibiotic for prophylaxis for 7-10 days, a cycloplegic agent (eg, atropine 1%) for about 1 month, and a topical steroid (eg, prednisolone acetate 1%) also for about 1 month. The intraocular pressure is monitored during the postoperative period and treated as necessary.

Deterrence/Prevention

The principal cause of a rhegmatogenous retinal detachment (RRD) is the formation of a retinal break following a PVD.

To prevent a RRD from occurring, one could try to find a way to prevent vitreous syneresis or PVD. So far, no such prevention method is available.

Another strategy would be to relieve vitreoretinal traction. The only known way to do this is through surgery (ie, scleral buckle, vitrectomy). However, the risks of these procedures do not justify their use in the prevention of a RRD.

The third strategy is to create chorioretinal adhesions around pre-existing retinal breaks and other visible predisposing lesions. One must consider whether other risk factors are present (eg, myopia, fellow eye RRD, family history, previous cataract surgery) and whether the patient is symptomatic. On one hand, asymptomatic patients with visible lesions (eg, lattice) probably have a very low risk for retinal detachment. These patients can be observed without treatment. On the other hand, myopic, pseudophakic patients with a RRD in the fellow eye with visible lesions should be strongly considered for prophylactic treatment.

Whether laser treatment is in fact beneficial in preventing a RRD in fellow eyes is not known. However, the adverse effects are minimal and the potential benefits are great. One must caution the patient that despite prophylactic treatment, a retinal tear still may occur. On the other hand, Wilkinson concluded that no conclusions could be reached about the effectiveness of surgical interventions to prevent retinal detachment in eyes with asymptomatic retinal breaks and/or asymptomatic lattice degeneration.^[56]

Individuals with a RRD have a higher risk of developing a RRD in the fellow eye if it is pseudophakic or has a more myopic refraction.^[57]

Complications

Potential complications include the following:

PVR is the most common reason for surgical failure.
Rubeosis iridis

Prognosis

Retinal reattachment surgery has improved; as many as 95% of patients can have an anatomic success. Visual prognosis depends on whether the macula is attached at the time of surgery. Once the macula is detached, the photoreceptors start to degenerate, impairing the visual recovery. Several factors affect the visual prognosis of a macula-off detachment. The most important factor affecting postoperative visual acuity is the preoperative visual acuity.^[58]

Persistent subfoveal fluid and increased preoperative foveal thickness are associated with a worse visual prognosis in macula-off RRD.^[59]One report states that a macula off detachment can be operated within the first 3 days after presentation without compromising the patient's visual prognosis.^[60]It is believed that only 50% of patients with a macula-off detachment attain a visual acuity of 20/50 or better. The height of the macula appears to also play a role in the postoperative visual acuity. Shallow macular detachments were associated with a better visual outcome.^[61]

In a retrospective longitudinal cohort analysis of 9216 Medicare beneficiaries diagnosed with a rhegmatogenous retinal detachment between 1991-2007, patients who had undergone primary pneumatic retinopexy were 3 times more likely to receive a second retinal detachment operation compared with scleral buckling or pars plana vitrectomy. Risk for additional retinal detachment surgery did not differ significantly between scleral buckling and pars plana vitrectomy. Patients who had a pars plana vitrectomy were twice as likely to suffer adverse events compared with those who had scleral buckling.^[62]

Spectral-domain optical coherence tomography may be used to predict the visual outcome after successful RRD repair. The status of the external limiting membrane, ellipsoid, and the outer nuclear layer are important determinants of postoperative visual acuity.^[63]

Patient Education

Warn patients who experience a retinal detachment of the potential risk to the fellow eye. In phakic eyes, the risk is estimated to be 10-15%. In aphakic or pseudophakic eyes, the risk increases to 25-40%.

Instruct patients to seek attention immediately if they start experiencing floaters and/or photopsias.

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Media Gallery

Clinical picture of a rhegmatogenous retinal detachment involving the macula. Notice the folds just temporal to the fovea.
Clinical picture of a rhegmatogenous retinal detachment. Notice that the macula is involved and that the retina is corrugated and has a slightly opaque color.
This patient had a vitreous hemorrhage that prevented visualization of the retina. A B-scan ultrasound reveals a retinal detachment.

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Author

Lihteh Wu, MD Ophthalmologist, Costa Rica Vitreo and Retina Macular Associates

Lihteh Wu, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Club Jules Gonin, Macula Society, Pan-American Association of Ophthalmology, Retina Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Bayer; Quantel Medical, Roche<br/>Received income in an amount equal to or greater than $250 from: Bayer Health; Quantel Medical, Roche.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Steve Charles, MD Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Additional Contributors

V Al Pakalnis, MD, PhD Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Teodoro Evans, MD Consulting Surgeon, Vitreo-Retinal Section, Clinica de Ojos, Costa Rica

Disclosure: Nothing to disclose.