SURVEY OF OPHTHALMOLOGY VOLUME 53  NUMBER 1  JANUARY–FEBRUARY 2008

DIAGNOSTIC AND SURGICAL

TECHNIQUES
MARCO ZARBIN AND DAVID CHU, EDITORS

Recent Trends in the Management

of Rhegmatogenous Retinal Detachment
Akrit Sodhi, MD, PhD, Loh-Shan Leung, MD, Diana V. Do, MD, Emily W. Gower, PhD,
Oliver D. Schein, MD, and James T. Handa, MD

Wilmer Eye Institute, The Johns Hopkins Hospital, Baltimore, Maryland, USA

Abstract. It has been nearly a century since Jules Gonin performed the first intervention for
rhegmatogenous retinal detachment, trans-scleral cautery, achieving successful outcomes in close to
50% of his cases. With the introduction of alternative surgical approaches in the last half-century,
including Charles Schepens’ scleral buckle technique and Robert Machemer’s pars plana vitrectomy,
the surgical success rates have risen to close to 90%. Nonetheless, despite dramatic progress in the
success of reattachment surgeries, reasonable disagreement exists as to which approach (or
combination of approaches) is the best form of surgical intervention for patients with rhegmatogenous
retinal detachments. In this review, the authors summarize the current knowledge of retinal
detachment, and examine emerging results from the first large scale, prospective, randomized,
controlled clinical trials addressing the efficacy of these surgical approaches for retinal detachment,
with the hope of identifying the most appropriate (evidence-based) therapeutic intervention for the
treatment of rhegmatogenous retinal detachment. (Surv Ophthalmol 53:50--67, 2008. Ó 2008
Elsevier Inc. All rights reserved.)

Key words. pars plana vitrectomy  pneumatic retinopexy  retinal detachment 

rhegmatogenous retinal detachment  scleral buckle technique  surgery

Historical Background
th
Prior to the mid 19 century, ophthalmologists had
struggled to provide an explanation for eye condi-
tions that resulted in dimness or loss of vision.
However, this changed in 1850, when Hermann von
Helmholtz revolutionized ophthalmology with his
invention of the ophthalmoscope. The first oph-
thalmoscope was actually invented by Charles
Babbage, an English mathematician, in 1847.
However, although he gave the device to a physician
for testing, it was laid aside and forgotten. Helm-
holtz, unaware of Babbage’s invention, developed
his own version of the ophthalmoscope three years
later. Helmholtz’s ‘‘eye-mirror,’’ consisting of four
plates of glass used to increase the number of rays
reflected into the eye, enabled ophthalmologists to
look inside a person’s eye and see details of the
living retina. Three years later, Adolf Coccius
improved Helmholtz’s eye-mirror by introducing
a large square plano mirror, which increased the

50
Ó 2008 by Elsevier Inc. 0039-6257/08/$--see front matter
All rights reserved. doi:10.1016/j.survophthal.2007.10.007
RETINAL DETACHMENT: MANAGEMENT TRENDS
amount of light that reached the back of the
patient’s eye, thereby enhancing visualization of
the retina. Using his modified ophthalmoscope,
Coccius first described retinal breaks, an observa-
tion that was repeated a year later by Albrecht Von
Graefe. However, it would be another half century
before ophthalmologists began to understand
the causal relationship between these retinal breaks
and what was then known as spontaneous retinal
detachment.
Indeed, in 1904, at the International Congress in
Paris, retinal detachment was declared untreatable.
Two years later, motivated by this pessimistic declara-
tion, in the chapter on retinal disease in the 4th
volume of the French Encyclopedia of Ophthalmol-
ogy, Jules Gonin wrote ‘‘in order to effectively fight
a pathological process, we must know its nature and
anatomic conditions. Only the study of pathogenesis
of spontaneous (retinal) detachment, based on facts
and not on hypothesis, will make it possible to find the
treatment of this disease.’’ Gonin, therefore, set out to
understand the pathogenesis of retinal detachment
in an effort to identify its treatment. Reviving the
abandoned work of Theodor Leber, Gonin realized
that the etiology of retinal detachment could be
traced back to small tears in the retina. He postulated
that curing retinal detachment would depend on
sealing these breaks. Over a decade later, Gonin
performed the first intervention for retinal detach-
ment, trans-scleral cautery, to close retinal breaks.
Using his ‘‘ignipuncture’’ technique, Gonin treated
a series of patients with retinal detachment secondary
to retinal breaks, achieving successful outcomes in
close to 50% of his cases. It would take another
decade for the ophthalmic world to accept his
innovative, but controversial, procedure. During this
time, further improvements to ignipuncture quickly
improved success rates. Gonin’s collaborator, Henri-
cus Jacobus Marie Weve, substituted penetrating
diathermy for heat cautery, and reported success
rates of 80% on ‘‘favorable cases.’’ Weve further
predicted the potential for 100% successful outcomes
as better techniques for repair of retinal detachment
evolved.
Improved success rates for repair of retinal
detachment have since benefited from further
advancements in surgical technique as well as
improved methods for ocular examination. How-
ever, it has been the introduction of alternative
surgical approaches in the last half-century that has
elevated surgical success rates closer to Weve’s
optimistic prediction. In 1951 Charles L. Schepens
introduced the scleral buckle technique for retinal
detachment,106 raising the rate of successful out-
comes for retinal reattachment surgery to close to
90%. For the next two decades, scleral buckling was
51
the principal surgical intervention for patients with
retinal detachment. In 1970 Robert Machemer
introduced pars planar vitrectomy as an alternative
surgical approach for patients with retinal detach-
ment.81,82 Vitrectomy soon became, and remains,
the preferred surgical intervention for patients with
complicated retinal detachment. In 1986 George F.
Hilton and W. Sanderson Grizzard introduced
pneumatic retinopexy, the first outpatient surgical
procedure for the treatment of retinal detach-
ment.62 Today, all three procedures are widely used
to treat patients with retinal detachment. Despite
dramatic progress in the success of reattachment
surgeries, however, reasonable disagreement exists
as to which approach is the best surgical interven-
tion for patients with retinal detachment.
Pathogenesis of Retinal Detachment
Retinal detachment occurs when the neurosen-
sory retina (NSR) separates from the retinal
pigment epithelium (RPE) and fluid accumulates
within this potential space. Although there are no
anatomic junctions between the NSR and RPE, weak
mechanical forces (e.g., fluid pressures, vitreous,
inter-photoreceptor matrix, interdigitations be-
tween the microvilli and the photoreceptors) and
metabolic forces (e.g., oxygenation) promote adhe-
sions between these two layers. Once these forces of
attachment are overwhelmed, a retinal detachment
can occur. There are four main types of retinal
detachment, named for their etiology: exudative
(serous), tractional, rhegmatogenous, and com-
bined tractional/rhegmatogenous retinal detach-
ment. This review will focus on rhegmatogenous
retinal detachment.
Rhegmatogenous Retinal Detachment
Rhegmatogenous retinal detachment (RRD), the
disease process Gonin studied in the early 20th
century, remains the most common cause of retinal
detachment. Three pre-requisites for the develop-
ment of RRD are 1) liquefaction of the vitreous, 2)
tractional forces that produce a retinal break, and 3)
a retinal break through which fluid gains access into
the subretinal space.52 Liquefaction of the vitreous
occurs naturally with aging (synchysis senilis) but
can be accelerated by significant myopia, surgical
and non-surgical trauma, and intraocular inflamma-
tion. Posterior vitreous detachment (PVD) usually
occurs as an acute event after significant liquefac-
tion of the vitreous gel. PVD is the consequence of
changes in the macromolecular structure of the
vitreous gel that result in liquefaction, concurrent
52 Surv Ophthalmol 53 (1) January--February 2008 SODHI ET AL

with alterations in the extracellular matrix at the people (0.01% annual risk), with a lifetime risk (up
vitreous--retinal interface that allow the posterior to 60 years of age) of 0.6%.57,131 Several well-
vitreous cortex to detach from the internal limiting established major risk factors have been described
lamina of the retina.109 The precipitating event is that significantly influence the risk of RRD de-
probably a break in the posterior cortical vitreous in velopment, including cataract surgery, high myopia,
the region of the macula, followed immediately by severe ocular trauma, ocular infections, lattice
the passage of intravitreal fluid into the space degeneration, and glaucoma.
between the cortical vitreous and retina. PVD often
precipitates RRD by producing the tractional forces CATARACT SURGERY
necessary to generate retinal breaks, allowing the
Patients who undergo cataract surgery comprise
liquefied vitreous to accumulate in the subretinal
only 3% of the general population, but include 40%
space. Thus, patients who are predisposed to early
of patients with RRD.80 Indeed, RRD is a significant
development of PVD are also at risk for developing
post-surgical complication for patients who undergo
RRD.
cataract surgery, with 50% of detachments occurring
However, the majority of retinal breaks do not
within the first year following surgery. The risk is
result in retinal detachment. In a cohort study, Byer
highest for patients who have intracapsular cataract
reported that asymptomatic retinal breaks discov-
extraction (ICCE). These patients have a 1.1--3.6%
ered in phakic, non-fellow eyes show almost no
risk of developing retinal detachment in non-
tendency toward clinical retinal detachment. For
myopic eyes (follow-up between 1 week and 5 years),
the total series of 235 eyes, the combined risk of
with myopic patients showing a higher incidence.80
retinal detachment, justifying treatment, was in the
This number increases to 7% if vitreous loss occurs
range of 1% to 2%.17 Indeed, several adhesive forces
during surgery. Post-cataract RRD tends to be more
may be sufficient to maintain the integrity of the
advanced, with total detachment (often involving
vitreous-retinal interface in the presence of a retinal
the macula), multiple tiny breaks, fixed folds, and
break, including adhesive-like mucopolysaccharides
a higher incidence of proliferative vitreoretinop-
(MPS) in the subretinal space, oncotic pressure
athy. The cause for this increased risk is unclear, but
differences between the choroid and the subretinal
is believed to involve liquefaction and collapse of
space, hydrostatic/hydraulic forces related to in-
the vitreous secondary to diffusion of hyaluronic
traocular pressure, and metabolic transfer of ions
acid during surgery. In addition, the loss of
and fluid by the RPE.52 RRD occurs only when these
adhesion between the vitreous and posterior capsule
adhesive forces are overwhelmed by vitreoretinal
causes increased traction with eye movement. Of
traction (often promoted by gravitational and
note, in patients who undergo ICCE in only one eye,
inertial—rotational eye movement—forces), allowing
and develop a retinal detachment in the operated
fluid to gain access to the subretinal space.
eye, the risk for RRD is also increased in the phakic
Patients with RRD often have a history of light
eye,111 which suggests that additional factors pre-
flashes or floaters followed by progressive visual field
dispose this patient population to RRD. The in-
loss.50 On clinical examination, patients may have
troduction of extracapsular cataract extraction
pigmented cells (‘‘tobacco dust’’) in the vitreous and
(ECCE; by either expression or phacoemulsifica-
occasionally in the anterior chamber. The underlying
tion) has significantly decreased the incidence and
detached retina is opaque with a corrugated appear-
extent of post-cataract surgery RRD. Using the 5%
ance, often undulates with eye movement, and the
random sample of Medicare beneficiaries, Javitt et al
subretinal fluid is usually clear. By definition, retinal
demonstrated that the cumulative probability of
break(s), although not always detected, must be
RRD within three years after ECCE surgery was
present. Treatment is surgical and requires closure of
0.81%.66 However, even in patients who undergo
the retinal break. If left untreated, symptomatic RRD
phacoemulsification, if the posterior capsule is
invariably results in loss of vision.104
disrupted, there is a significant risk for the sub-
sequent development of RRD.
RISK FACTORS
Extrapolating from regional studies, the annual HIGH MYOPIA
incidence of RRD in the United States is approxi- Patients with high myopia, defined as a spherical
mately 36,000.57,131 With appropriate surgical in- equivalent of --6.0 diopters (D) or more or an axial
tervention, anatomic success rates of 90--95% can be length of at least 26 mm, have an approximately five-
achieved; nonetheless up to 40% of treated patients to six-fold increased risk for developing retinal
have visual acuity of 20/50 or worse.27 In the general detachment.28 These patients make up only 10%
population, RRD occurs in about 12 out of 100,000 of the general population but comprise 42% of all
RETINAL DETACHMENT: MANAGEMENT TRENDS
patients with RRD.6 Using Cox’s proportional
hazards regression model, Ninn-Pedersen and
Bauer demonstrated that the risk for RRD is directly
related to the degree of myopia; an increase in axial
length of 1 mm increases the risk of RD by a hazard
ratio of 1.3.92 The cause for this association is
believed to be multi-factorial, and likely involves the
increased risk for lattice degeneration (see sub-
sequent discussion), posterior vitreous detachment,
and the increased incidence of thin retinas in high
myopes.
LATTICE DEGENERATION
Lattice degeneration is an elliptical area of
thinning (degeneration) of the inner retinal layers
(most often occurring in the peripheral retina,
parallel to the ora serrata) and localized liquefac-
tion of the overlying vitreous marked by a criss-
crossing lattice network of hyalinized blood vessels.79
Lattice degeneration can occur early in life and
peaks in the second decade. Patients with lattice
degeneration make up 6--7% of the general popu-
lation but comprise 41% of patients with RRD.6
Seventy percent (70%) of patients with lattice
degeneration who develop RRD are under 40 years
old. Lattice degeneration is more common in
myopic patients, occurring in 15% of eyes with
axial length of 30 mm or more.68 The pathogenesis
of lattice degeneration is unknown.
Lattice degeneration is the most important
peripheral retinal degeneration that predisposes to
a RRD. In almost one third of patients with lattice
degeneration, atrophic round holes in the retina are
present.18 Lattice degeneration is directly responsi-
ble for the detachment in approximately 21% of
patients with RRD.11 However, unlike post-cataract
surgery RRD, retinal detachments secondary to
lattice degeneration tend to progress slowly, and
are associated with surgical success rates of 98--
100%.11
OCULAR TRAUMA
Blunt trauma is the leading cause of RRD in
children and adolescents.91 The vast majority of these
patients are male.103 Boxers are at particularly high
risk.83 Following blunt trauma, rapid compression of
the eye along its anterior-posterior diameter results in
tractional forces at the vitreous base upon re-
expansion of the eye.128 which can, in turn, induce
linear retinal tears and dialysis.31 These breaks usually
occur at the time of impact, but detachment
progresses slowly and carries a good prognosis.31,91
Retinal detachments occur in 20% of patients
with posterior segment penetrating injuries, and is
4.5 times more likely if vitreous hemorrhage is
53
present.95 Late retinal breaks may also occur with
contraction of the episcleral fibrovascular tissue,
which can proliferate into the intravitreal space at
the site of penetration.30 In both scenarios, patients
with retinal detachment secondary to penetrating
trauma have a poor prognosis.30,40
OCULAR INFECTIONS
AIDS patients are at increased risk of developing
CMV retinitis, 38% of whom will go on to develop
RRD within one year of diagnosis.34 Patients with
endophthalmitis are also at risk for RRD; this risk
can be significantly decreased by treating the
infection with either antibiotics or vitrectromy.38
GLAUCOMA
Four to seven percent of patients with RRD have
open-angle glaucoma, compared to less then 1% of
the general population.97 Patients with congenital
glaucoma are similarly at increased risk for RRD.
Although still unclear, it appears that the increased
incidence of high myopia in individuals with
glaucoma, combined with the use of miotic agents
in these patients, may help explain the relationship
between glaucoma and RRD.98
GENETICS
Several syndromes have been described in which
RRD is a common feature. With current advances in
gene mapping and the recent sequencing of the
human genome, many of the genetic mutations that
produce these syndromes are being identified;
combined with improved accessibility to genetic
testing for these syndromes, this may ultimately
enable early detection and intervention for retinal
detachment. For further information, please see the
reviews by Abboud1 and Richards.99
STICKLER SYNDROME
In 1965, Gunner B. Stickler first described
a dominantly inherited syndrome with a predomi-
nant skeletal and eye phenotype.116 Although
significant inter-familial variability exists, individuals
with Stickler syndrome most often manifest pro-
gressive myopia and a congenital membranous
anomaly that can lead to retinal detachment, in
addition to abnormal epiphyseal development with
premature degenerative joint disease. Stickler syn-
drome is the most common cause of RRD in young
children, with most cases leading to total blindness
if not diagnosed early. In a recent survey, 61% of
adults and 20% of children with Stickler syndrome
acknowledged suffering from retinal detachment.117
Stickler syndrome (type 1) recently has been linked
54 Surv Ophthalmol 53 (1) January--February 2008
to mutations in type II collagen.45,46 A second form
of Stickler syndrome (type 2) has been linked to
dominant negative mutations in type XI colla-
gen,15,100 but is less often associated with retinal
detachment.
MARSHALL SYNDROME
Marshall syndrome was first described in 1958 as
a dominantly inherited syndrome with multiple
ectodermal abnormalities including cataracts, myo-
pia, abnormal vitreous, midfacial hypoplasia, deaf-
ness, and anhydrosis.85 Patients with Marshall
syndrome also suffer from RRD. Due to the clinical
similarities with Stickler syndrome and linkage to
mutations in type XI collagen,54 it is debated
whether Marshall syndrome is a form of Stickler
syndrome. However, due to distinctions in clinical
presentation, recent studies suggest the two may be
separate syndromes.9
WAGNER SYNDROME
In 1938, Hans Wagner described a dominantly
inherited syndrome characterized by genu valgum,
vitreoretinopathy, cataracts, and changes in the RPE
causing difficulty with night vision and visual field
defects.127 Eighteen percent of individuals with
Wagner syndrome suffer from RRD. Although
linkage studies suggest the mutation associated with
Wagner syndrome is located on chromosome 5,13,96
the gene(s) involved are still unknown. Erosive
vitreoretinopathy (ERVR) may be a variant of
Wagner syndrome with a translucent erosion of
the RPE.14 Seventy-three percent of individuals with
ERVR will have a retinal detachment. The genetic
cause of ERVR is unknown.
KNOBLOCH SYNDROME
In 1971, William H. Knobloch described a rare
recessive syndrome characterized by midfacial
hypoplasia, a flat nasal bridge, high myopia, retinal
detachment, and an occipital enephalocele.71 The
cause of this syndrome was later identified as
a mutation in type XVIII collagen.118
FAMILIAL EXUDATIVE VITREORETINOPATHY
Familial exudative vitreoretinopathy is a rare
disease first described in 1969 with a highly variable
presentation characterized by vitreoretinopathy,
falciform retinal folds, and recurrent vitreous
hemorrhages.32 Two forms have been described,
an autosomal dominant form caused by mutations
in Frizzled 473,102 and low-density lipoprotein re-
ceptor-related protein 5 (LRP5),67,122 key molecules
in the Wnt signaling pathway, and an X-linked form
SODHI ET AL
caused by a mutation in the Norrie disease gene.25
Twenty percent of patients with familial exudative
vitreoretinopathy suffer from RRD.
MARFAN SYNDROME
Marfan syndrome was first described in 1896 by
Antoine Bernard-Jean Marfan as a dominantly
inherited fibrous connective tissue disorder charac-
terized by ocular, skeletal, and cardiovascular de-
fects. More recently, the genetic cause of Marfan
syndrome has been identified as mutations in the
gene for fibrillin 1.37,78,86 Individuals with Marfan
syndrome have very thin and collapsible sclera, with
loss of elasticity and stretching leading to axial
myopia. The increased incidence of high myopia
and peripheral lattice degeneration predisposes
these eyes to retinal breaks and detachment. RRD
has been reported to occur in 8% to 12% of patients
with Marfan syndrome,33,87 but may be as high as
38% in the presence of lens dislocation. There is
also a high incidence of bilateral RRD, occurring in
up to 69% of patients with retinal detachment in
patients with Marfan syndrome.1
EHLERS-DANLOS SYNDROME
Ehlers-Danlos syndrome comprises a heteroge-
neous group of connective tissue disorders charac-
terized by skin hyperextensibility, tissue fragility, and
joint hypermobility. Ocular involvement is a rare
occurrence but includes corneal and scleral rupture
from minor blunt injury, lens displacement, and
RRD.10 Surgical repair of retinal detachments in
patients with Ehlers-Danlos syndrome is further
complicated by their weak sclera and fragile
choroidal blood vessels owing to their compromised
collagen framework.94
OTHER SYNDROMES
Other syndromes that predispose to rhegmatog-
enous retinal detachment include a group of related
diseases in which RRD is a primary feature (domi-
nantly inherited RRD), as well as syndromes in
which there is an increased frequency for RRD
secondary to known risk factors (high myopia,
lattice degeneration, etc.).
Intervention
SCREENING FOR RRD
Due to its rare incidence in the general popula-
tion, there is currently no justification for the
general screening of patients for retinal detach-
ment, or for predisposing lesions.8 Nonetheless,
RRD remains an important cause of preventable
RETINAL DETACHMENT: MANAGEMENT TRENDS
vision loss. Significant morbidity is associated with
macular detachment before RRD is treated, and in
most cases, this detachment occurs before pre-
sentation. A small increase in the number of
patients who present for surgery with an intact
macula could result in a dramatic decrease in visual
morbidity associated with RRD. Appropriate educa-
tion of patients at risk for retinal detachment is
necessary to encourage symptomatic patients to
present before macular detachment occurs and
would likely improve treatment outcomes.
PREVENTION
Prevention of RRD remains an important concern
as surgical and anatomic success is not always
followed by visual success. Prophylactic treatment
of RRD could be achieved by first identifying
patients with peripheral retinal degenerations that
are at high risk for developing a retinal detachment,
and preventing progression to retinal detachment.
Lattice degeneration, degenerative retinoschisis,
cystic retinal tufts, and zonular traction tufts, have
been identified as significant risk factors for RRD.
Consequently, these lesions have been considered
for prophylactic therapy.
Although lattice degeneration is a risk factor for
development of a RRD, less than 1% of patients with
lattice degeneration develop a retinal detachment,
and up to 60% of RRDs are not associated with
lattice degeneration.6 Nonetheless, as lattice de-
generation is present in 30% of phakic RRD, these
lesions have been considered for prophylactic
therapy.132 However, without other predisposing
factors, lattice degeneration rarely causes a retinal
detachment. The risk for RRD in eyes with lattice
degeneration is approximately 1% per year (fol-
lowed over 11 years) if the fellow eye has not had
a retinal detachment.19 Currently, there is no
scientific evidence to suggest that prophylactic
treatment of lattice degeneration with or without
retinal holes in phakic, non-fellow eyes, is beneficial.
Therefore, in asymptomatic patients without other
risk factors, prophylactic treatment is generally not
recommended.19 However, prophylactic treatment
might be considered if there is evidence of lattice
degeneration in the fellow eye of a patient with
a history of RRD in the first eye (especially if the
visual function is poor in this eye), the patient does
not have or has minimal access to ophthalmic care,
or if the patient might have difficulty recognizing
the symptoms of a posterior vitreous separation.19
Retinoschisis represents splitting of the neurosen-
sory retina into two layers. This condition is not
a retinal detachment, although an RRD can occur
in eyes with retinoschisis and retinal breaks.
55
Retinoschisis is present in up to 6% of retinal
detachments, but is responsible for less than 2.5%
of all RRDs.79 Prophylactic treatment is generally
not recommended for asymptomatic patients with
retinoschisis with or without outer retinal holes or
with localized, nonprogressive, retinal detachments.
Patients with retinoschisis should instead be fol-
lowed periodically and instructed to return imme-
diately if they become symptomatic.
A cystic retinal tuft is a congenital abnormality
that occurs during the development of the periph-
eral retina, clinically characterized by a small,
discreet, round or oval, elevated chalky-white vitre-
oretinal lesion. Vitreous condensations are attached
to its surface, and its base may have pigmentary
changes. It is estimated that up to 10% of RRDs are
caused by retinal tears in areas of cystic retinal
tufts.79 However, as the risk of developing a RRD
from a cystic retinal tuft is low, and because the
natural history and the results of treatment of cystic
retinal tufts have not been studied, prophylactic
treatment is currently not indicated.
In zonular traction tufts, thickened zonules are
displaced posteriorly toward the anterior retina
resulting in an anterior projection or tuft of the
retina. Zonular traction tufts are present at birth
and are found in 15% of cases seen at autopsy, and
are bilateral in 15%. Retinal detachment can rarely
occur, caused by the development of retinal breaks
in association with the zonular traction tuft.79 The
traction at the apex can result in a retinal tear (flap
or operculated), and the trophic changes at the base
can cause a retinal hole. Because these lesions are
mostly intrabasal, retinal breaks are typically not
clinically significant. When a retinal detachment
occurs, it is frequently localized and nonprogressive.
Therefore, prophylactic treatment of these lesions is
currently not indicated.79
The risk for bilateral RRD is highly variable
depending on the population studied and their
associated risk factors, but ranges from 6.4--34%.56
As retinal detachment in the fellow eye of a patient
with pre-existing RRD is a significant threat to vision
and quality of life, prophylactic treatment for these
patients has the potential of preserving vision. Risk
factors for RRD in the fellow eye include those
factors that predispose patients to primary RRD (see
previous discussion). Although many of these risk
factors have been identified, it remains unclear
whether these patients, in the absence of symptoms,
would benefit from prophylactic treatment to pre-
vent RRD. Recently, Avitabile et al conducted a
retrospective study to examine the efficacy of pro-
phylactic treatment of the fellow eye of patients with
RRD.7 Although the reported incidence of bilater-
ality of RRD after prophylaxis (photocoagulation,
56 Surv Ophthalmol 53 (1) January--February 2008
cryotherapy, or scleral buckle) was significantly
lower than that reported in the published literature
(1.2% vs. 13.4%,44 respectively), the impact of this
retrospective study on the decision to prophylacti-
cally treat fellow eyes for RRD remains to be
determined.
Ultimately, prophylactic treatment of retinal
breaks can only be justified if the risk of complica-
tions from treatment is lower than the risk of breaks
leading to clinical retinal detachment. Current
evidence supports prophylactic treatment only for
symptomatic tractional tears, and is suggestive for
the treatment of large, symptomatic operculated
holes, high-risk fellow eyes of nontraumatic giant
retinal breaks, retinal breaks with subclinical retinal
detachments threatening progression, and retinal
breaks before cataract surgery.69 Asymptomatic
retinal breaks in phakic eyes with lattice degenera-
tion, high myopia, and fellow eye detachments show
no significant benefit from prophylactic treat-
ment.69 It is therefore recommended that patients
with peripheral retinal degenerations that are at
high risk for developing a retinal detachment, be
educated for the signs and symptoms of posterior
vitreous detachment and instructed to seek oph-
thalmologic care immediately if these symptoms
develop.
TREATMENT OF ASYMPTOMATIC RETINAL
DETACHMENT
A range of management strategies for asymptom-
atic retinal detachments has been proposed, from
the more conservative (observation) to the more
aggressive (surgery). In a recent study, Greven et al
described a series with asymptomatic RRD patients
(half of whom were discovered on routine exam)
undergoing scleral buckle.53 All eyes had good
anatomic and functional results, suggesting that
surgical management should be considered for
asymptomatic RRD. However, Vrabec and Baumal
demonstrated that certain asymptomatic macula-
sparing retinal detachments may not need surgical
intervention, despite the increased risk of pro-
gression to macular detachment.126 In this study
demarcation laser photocoagulation of shallow,
macula-sparing, RRD without associated PVR was
demonstrated to be a reasonable alternative to
surgical repair, even eyes that had established risk
factors for progression, including horseshoe tears,
vitreous hemorrhage, or a detachment in the fellow
eye. Conversely, in a prospective cohort study, Byer
recently reported that the incidence of progression
of subclinical retinal detachment resulting from
asymptomatic retinal breaks to clinical retinal de-
tachment is less than 1% per year.16 Similarly, in
SODHI ET AL
a prospective observational case series, Cohen
showed that all 18 asymptomatic untreated RRDs
remained asymptomatic for an average follow up of
46 months.29 Collectively, the latter studies suggest
that asymptomatic RRDs in selected cases, may be
safely observed for many years with routine exam-
inations and appropriate patient education on
symptoms of retinal detachment.
SURGICAL APPROACHES
Although the benefit for treatment of asymptom-
atic RRD remains unclear, symptomatic RRD is
a clear indication for surgery. However, over the
last two decades, the risks and benefits of the three
surgical approach(es) for RRD have been the
subject of controversy (Table 1). Numerous studies
have reported therapies for retinal detachment for
various indications, but few adequately powered,
randomized, controlled trials have been conducted
to date that have demonstrated the superiority of a
single technique. Moreover, repair of RRD often
involves a combination of surgical approaches. Of
note, Minihan et al demonstrated that both primary
(80--84%) and final (89--94%) anatomic success
rates for retinal detachment repair in 1999 are
similar to those reported in 1979,89 despite obvious
surgical and technological advancements. These re-
sults suggest that the careful selection of the appro-
priate management strategy remains a necessity.
SCLERAL BUCKLING
Scleral buckling (SB) surgery has been consid-
ered the ‘‘gold standard’’ for uncomplicated RRD.
Final anatomic success rates of greater than 94%
after SB surgery have consistently been reported,
and a recent retrospective follow-up study by
Schwartz et al demonstrated the stability and
longevity of the procedure, with 95% reattachment
at 20 years.108 Vision is preserved, with postoperative
visual acuity in uncomplicated RRD of 20/50 or
better. The most common reported cause of failure
in surgery for retinal detachment is proliferative
vitreoretinopathy (PVR).5 If PVR develops, patients
typically require further surgical intervention, in-
cluding vitrectomy. Detachment of the choroid is
a frequently reported complication following scleral
buckling surgery. However, recent evidence suggests
that the frequency of choroidal detachments after
SB (2.4%) may be similar to that following PPV
(2.1%).3 Choroidal detachments usually develop
one or two days after surgery and may increase in
size for two or three days. However, they usually heal
within two weeks without further treatment.
RETINAL DETACHMENT: MANAGEMENT TRENDS
TABLE 1
Surgical Approaches for the Repair of Rhegmatogenous Retinal Detachment
Method Reattachment Rate
Scleral buckling O94%
Pars plana vitrectomy 71--92% (primary
sucess); 95%
(final sucess rate)
Pneumatic retinopexy 64% (primary);
91% (final)
(use limited to
uncomplicated
RRD in superior
quadrants, including
both phakic and
pseudophakic/
aphakic eyes)
Commonly cited disadvantages of SB surgery
include intraoperative hemorrhage or retinal in-
carceration during drainage. Additionally, small or
multiple breaks may not be identified in the SB
procedure, although definitive data on the preva-
lence of missed breaks are lacking. Postoperatively,
disadvantages include prolonged recovery time,
pain, induced refractive error with increased myo-
pia, floaters, and ocular motility disturbances. Un-
usual risks include vitreous or subretinal
hemorrhage, infection, swelling or inflammation
of the macula, cataracts, increased intraocular
pressure, and complications of the buckle, includ-
ing distortion of the shape of the eye (causing
a refractive error and affecting vision) and in-
terference with extraocular muscles (leading to
strabismus or diplopia). The most frequent re-
ported complication after SB was ocular motility
disturbance although usually temporary. Long-term
diplopia however, is seen in 5--25% of patients.42
Deokule et al report that the most common reasons
for scleral explant removal after RRD repair are
extrusion, pain, infection, and scleritis/redness.35
Some of these complications might be prevented
with use of a segmental buckle instead of an
encircling band, without a significant difference in
reattachment rates.75 Factors associated with ana-
tomic failure of scleral buckling include the
presence of multiple retinal breaks, breaks larger
than three quadrants or three disc diameters, and
detachments lasting longer than one week. Poor
visual outcome has been associated with these
factors as well as macular detachment and poor
preoperative visual acuity.55,137
57
Risks/Complications Benefits
Pain, infection, Excellent anatomic
buckle extrusion, results, longevity,
ocular motility good visual outcomes
disturbances
Vision-threatening Visualization of the
complications, all tears/breaks, removal of
including iatrogenic opacities/synechiae,
retinal breaks, PVR, anatomic sucess in
lens trauma, cataract complicated detachments
progression
Redetachment risk In-office procedure, minimally
(no relief of invasive, reduced
vitreoretinal traction), recovery time, better
necessity for postoperative visual acuity
postoperative
positioning
The method for and the use of retinopexy and SB
has been a subject of interest over the last few years.
Cryotherapy, though frequently used in the past and
easy to apply, is thought to compromise the blood--
ocular barrier, ultimately increasing the likelihood
of PVR.115 Thus, laser photocoagulation has been
used as an alternative. In a randomized, controlled
trial comparing cryotherapy to laser photocoagula-
tion, using visual recovery and flare as primary
outcomes, Veckeneer et al showed that a significantly
higher level of flare, as measured by photometry,
was seen with cryotherapy at all time points.125 In
contrast, Steel et al compared transscleral diode
laser to cryotherapy in a randomized trial, finding
both that anatomic success was higher (92% vs.
83%), and PVR less frequent (3% vs. 5%) in the
cryotherapy group.115 In a randomized trial of 60
patients with small retinal breaks undergoing
encircling buckle, Figueroa et al reported that
90% of patients were successfully reattached despite
undergoing no cryopexy, as compared to 87% of
patients who underwent cryopexy.43 Similarly, final
visual acuity improved by two lines or more in 73%
of patients without cryopexy, compared to 67% of
patients with cryopexy. They proposed that some
cases of RRD may be treated successfully without
retinopexy. Conversely, the application of prophy-
lactic 360 laser retinopexy may be an effective
method of reducing the incidence of retinal
redetachment in the same eye. Laidlaw et al found
a significant reduction in the incidence of retinal
redetachment after the removal of silicone oil
tamponade in patients undergoing laser retino-
pexy.76 Retinopexy post scleral buckle remains an
58 Surv Ophthalmol 53 (1) January--February 2008
active area of research and may further influence
the success rate of SB repair for RRD.
PARS PLANA VITRECTOMY
In the past, pars plana vitrectomy was used as the
primary surgical intervention only in complicated
retinal detachments, including those with vitreous
hemorrhage (i.e., when the view of the retina is
obscured), breaks in the posterior pole, or pro-
liferative vitreoretinopathy. The ability to visualize
all retinal breaks and tears, as well as the removal of
opacities and synechiae, are advantages of the
procedure. Indeed, the use of adjuvant dyes (e.g.,
trypan blue) to stain the subretinal fluid may help
identify occult breaks.65 Nonetheless, missed retinal
breaks remain the most common cause of failure of
primary PPV for RRD,101 emphasizing the impor-
tance of preoperative retinal examination for all
cases of RRD.
Favorable reattachment rates with low intraoper-
ative complication rates have made PPV an in-
creasingly popular primary option for RRD repair.
In fact, Minihan et al reported that almost two-thirds
of RRD cases at a vitreoretinal center in the UK
underwent primary PPV in 1999.89 Recent studies
have confirmed the success of PPV in complicated
RRD: In a retrospective study of 205 eyes, Schmidt et
al describe a primary anatomic success rate of 71%
and a final anatomic success rate of 95% in
detachments complicated by PVR, pseudophakia,
or large or posterior pole breaks.107 Similar results
were reported by Gartry et al in patients with
primary RRD without proliferative retinopathy,
achieving 74% retinal reattachment with one
procedure, and with further surgery, a 92% ana-
tomic success rate.51 Vitrectomy for large retinal
breaks or multiple peripheral breaks is successful,
with a 92% single-procedure attachment rate, with
greater than 93% achieving at least two lines of
visual improvement.
Disadvantages of PPV include the need for post-
operative positioning, avoidance of flying or travel-
ing to altitude with a gas bubble in the eye, and an
extended recovery time that is dependent on the
type of gas placed. Serious complications after PPV
are more frequent than with SB. Afrashi et al
reported iatrogenic retinal breaks in more than
7% of patients, and PVR in more than 9% after
PPV.2 In a recent retrospective observational case
series, Chang reviewed the records of 453 eyes that
had undergone vitrectomy for postoperative open-
angle glaucoma.23 In glaucoma suspects, the mean
intraocular pressure was significantly higher in the
operated eye compared with the fellow eye. In eyes
with new onset glaucoma, 68% had it in the
SODHI ET AL
vitrectomized eye only. In eyes with glaucoma prior
to vitrectomy, the mean number of antiglaucoma
medications that were required to control the
intraocular pressure was significantly higher in the
vitrectomized eye, compared with the fellow eye.
Of note, Wright et al recently reported that ocular
motility problems—traditionally viewed as a frequent
complication for RRD repair by SB—have a similar
incidence in RRD repair by PPV.135 It has been
suggested that local anesthetic myotoxicity is often
the primary cause of strabismus occurring after
scleral buckling procedures for retinal detach-
ment.105 The increased amount of local anesthetic
typically given with SB procedures may account for
the more common association of strabismus with SB
rather than PPV.
Other complications after PPV include lens
trauma (in more than 9%) and postoperative
cataract (nuclear sclerosis) progression, occurring
in 81% and 98% of vitrectomized eyes compared to
18% and 20% of control fellow eyes, at 6 months
and 1 year, respectively.26
One of the most innovative vitreoretinal surgery
techniques introduced in recent years is trans-
conjunctival sutureless vitrectomy (TSV) using
a 25-gauge incision, developed by Fujii et al in
2002.48,49 In this procedure, three polyamide micro-
cannulas are inserted transconjunctivally through
the sclera in the area of the pars plana. The
vitreoretinal instruments and infusion line are then
introduced through these cannulas into the vitreous
cavity. Because a thin 25-gauge instrumentarium is
used, the incisions left in the sclera after removal of
the cannulas are so small that they seal without
suturing, thereby minimizing surgically induced
trauma, and decreasing the convalescence period,
operating time, and postoperative inflammatory
response.
Two recent outcome studies on patients with 25-
gauge TSV corroborate these expectations. In
a retrospective study of 140 eyes, Lakhanpal et al
reported no intraoperative complications and no
cases requiring conversion to traditional 20-gauge
machines.77 Similarly, Ibarra et al reported no
intraoperative complications in 45 eyes that un-
derwent TSV.64 However, postoperative complica-
tions, including retinal detachment, were noted.
Current evidence supports the use of 25-gauge TSV
only in less complicated vitreoretinal surgery. In-
deed, one of the most frequent objections of TSV is
that the 25-gauge instruments are too flexible for
many of the complicated tasks performed on the
retina and vitreous body, including RRD. The
introduction of a 23-gauge system may help over-
come this flaw.39 Ultimately, studies comparing
these novel approaches with traditional surgical
RETINAL DETACHMENT: MANAGEMENT TRENDS
approaches will be needed to determine the specific
circumstances where TSV may be best suited for
treatment of RRD.
PNEUMATIC RETINOPEXY
Pneumatic retinopexy (PR) has traditionally been
indicated for uncomplicated RRD, including supe-
rior retinal breaks smaller than one clock hour, or
multiple breaks not extending for more than one
clock hour. Contraindications include inferior
breaks, PVR, lattice, media opacities, uncontrolled
glaucoma, and pseudophakia or aphakia. Fre-
quently cited advantages of the minimally invasive
procedure include reduced postoperative morbidity
and recovery time.63 Disadvantages of the procedure
include the necessity for correct postoperative
positioning and close follow-up, as well as the
avoidance of air travel in the immediate postoper-
ative period.124 The most frequent problems from
pneumatic retinopexy include misplaced gas in-
jection, PVR, and persistent subretinal fluid or
trapped gas. More rarely, patients may experience
endophthalmitis, macular folds, an increase in
intraocular pressure, choroidal detachment, and
vitreous or subretinal hemorrhage. The most serious
complication of PR reflects the nature of the
procedure. Because PR does not relieve vitreoretinal
traction (as opposed to SB or PPV), new breaks may
form, previously unidentified breaks may be recog-
nized, or the original break may reopen. These
issues are manifest by a more common need for
more than one surgery to reattach the retina after
PR than with either SB or PPV. In a retrospective
study by Eter et al, 19.4% of reattached retinas
redetached during the first three months post-
procedure, with an additional 4.5% redetached
after 6 months.41 Moreover, Ambler et al reported
that RRDs that initially fail PR, that are then treated
with repeat PR have a higher failure rate than RRDs
treated with primary PR (38% vs. 23%).4 Although
a failed attempt at PR does not appear to disadvan-
tage the eye for reoperation with SB, suitable criteria
for selection of candidates for primary PR are
warranted. Additionally, the appropriate secondary
surgical approach (PR vs. SB or PPV) for RRDs that
fail (or redetach after) PR remains to be addressed.
The use of inverted pneumatic retinopexy for
treating RRD associated with inferior retinal breaks
was recently reported by Chang et al.24 Initially
suggested by Friberg and Eller in 1988,47 this
procedure requires inverted positioning of the
patient after placement of the gas bubble. Chang
et al demonstrated that positioning of the patient
for 8 hours was sufficient for retinal reattachment,
suggesting that long acting gas bubbles (and
59
prolonged positioning up to 16--21 hours a day for
1--3 weeks after the surgery) may not be necessary
for successful RRD repair by PR.
VITREOUS SUBSTITUTES
Recent advances in the development and use of
intravitreally injected fluids (e.g., collagen and
hyaluronic acid, gases, silicone oils, perfluorocarbon
liquids and, most recently, polymer hydrogels) has
also played an important role in facilitating retinal
reattachment surgery. Artificial vitreous substitutes
used clinically include gases (air and perfluorocarbon
gases) and liquids (silicone oil and perfluorocar-
bon liquids). These fluids are used to re-establish
intraocular volume, assist in separating membranes
adherent to the retina, manipulate retinal de-
tachments, and mechanically flatten detached
retina (see Soman113 for review).
First used as a vitreous substitute in 1911, air
successfully provided both retinal tamponade and
volume replacement.22 However, the major problem
with air is its rapid absorption from the vitreous
cavity by diffusion across the retina, therefore
limiting its tamponade effects to a few days. Air
therefore is not a practical long-term vitreous
tamponade agent. Perfluorocarbon gases, intro-
duced in the 1980s, expand after intravitreal
injection and remain in the vitreous longer than
air to improve the effectiveness of tamponading.134
However, patients who receive gas tamponade must
be monitored closely as gases have been associated
with lens opacification and high intraocular pres-
sure. To be effective, the patient must assume
a specific position to maximize the tamponading
effect after the operation. Gases are frequently used
for pneumatic retinopexy.
Although it was approved by the FDA for its use in
vitreoretinal surgery in 1994, silicone oil has been
used as a vitreous substitute since the 1960s.136
Silicone oil is injected into the vitreous cavity that
has previously been filled with air and remains in
the vitreous cavity until it is surgically removed.
Silicone oil facilitates the closure of the retinal
breaks and reduces subretinal leakage. However, the
low density of silicone oil can result in a reduced
tamponading effect for inferior retinal tears. More-
over, the persistence of silicone oil over long periods
(6 months) can lead to vision-threatening compli-
cations of cataract, glaucoma, and keratopathy.
Conversely, the recently emerging vitreous substi-
tutes, perfluorocarbon liquids are practically inert,
yet they have a longer intravitreal residence time
than gases.72 Over extended periods (greater than
one week), they can induce irreversible damage to the
inferior retina, preventing their use as a long-term
60 Surv Ophthalmol 53 (1) January--February 2008
vitreous substitute. Nonetheless, perfluorocarbon
liquids show promise as a unique compromise
with many of the benefits of both gases and other
liquids.
Analysis of Primary Surgical
Approaches for RRD
PROVIDER OUTCOME
A national audit of the outcome of primary
surgery for RRD has revealed that the overall
reattachment rate with a single procedure is
77%.120,121 However, the success rate after a single
procedure was significantly higher among vitreor-
etinal specialists (82%) than among non-specialists
(71%). This disparity was more striking in the
treatment of patients with more complex forms of
RRD (80% vs. 68%, respectively). These results,
likely influenced by the type and complexity of
surgical procedure(s) performed by specialist versus
non-specialists, suggest that RRD may be managed
best by vitreoretinal surgeons. These data also
suggest a lower surgical repair rate than is currently
believed by most vitreoretinal surgeons. Part of the
lower rate may be explained by the surgical
reattachment benchmark being determined after
a single procedure.
CLINICAL OUTCOME
Currently, the clinically defined endpoints of
successful RRD surgery are retinal reattachment
and repair and closure of all retinal breaks. Un-
fortunately, quality of vision and quality-of-life issues
associated with these surgeries have only rarely been
incorporated into outcome assessment, limiting the
inferences that can be drawn from the literature
related to the relative benefits of one surgical
approach compared to another. Appropriately
measuring the success of RRD surgery should
require examination from multiple perspectives,
not just traditional, anatomic ones. Patients un-
dergoing surgical treatment for RRD may require up
to a few months for complete post-surgical recovery.
Although modern day RRD surgery is associated
with relatively high single-operation success rates of
60--95%, patients frequently suffer from a variety of
post-surgical problems including diminished visual
acuity, loss of eye motility and misaligned eyes
causing diplopia, protracted periods of post-surgical
convalescence, cataract, significant anisometropia,
and postoperative pain and discomfort. Subsequent
re-detachments are not uncommon in patients, even
following a ‘‘successful’’ RRD repair. A persuasive
evaluation of surgical approaches for RRD must,
therefore, also include long-term outcome studies
SODHI ET AL
(need for multiple surgeries, etc.), as well as an
assessment of patient satisfaction post-procedure.
In general, primary repair of RRD with SB usually
lasts one to two hours. Repeat surgeries or more
complex detachments may take longer. Patients are
instructed to wear a patch over their eye for a day or
more. Patients experience pain for a variable period
following surgery. Common complaints include
a swollen, red, or tender eye that may last for several
weeks. Patients also may complain of reduced vision
due to the scleral buckle distorting the shape of
the eye, or problems due to the buckle interfering
with extraocular muscles leading to strabismus or
diplopia.
Uncomplicated PPV also takes one to two hours.
Patients go home with a patch on the eye that is
removed the day after surgery. Several follow-up
visits may be required during the first month;
however, follow up visits after the first month are
less frequent. Patients are usually able to return to
normal activity within a few weeks. Most of the
healing occurs during the first month, but full visual
recovery may take a few months. At the time of
vitrectomy surgery, air or gas bubble placement is
also performed, which may present additional
morbidity and complications (see subsequent dis-
cussion). If silicone oil is used instead of a gas
bubble, patients usually experience a quicker visual
recovery, no restriction on air travel, less need for
head positioning after surgery, and a longer dura-
tion of effect. However, silicone must be removed
during a second surgery, and removal may cause
a decrease in intraocular pressure, and, more rarely,
the development of cataracts.20,21
SOCIETAL OUTCOMES
Comparatively speaking, retinal procedures are
among the most expensive ophthalmic surgeries. In
addition to standard surgical costs (operating room
time, nursing and surgical staff, anesthesia, etc.),
initial investment may include the purchase of
a vitrectomy unit with a light source (approximate
cost, $60,000), an argon laser with an endolaser or
indirect laser attachment (approximate cost,
$90,000), and a cryotherapy unit (approximate cost,
$7,000), in addition to various instruments and
supplies. Based on 2004 national Medicare maxi-
mum physician and facility reimbursement figures,
PPV and SB have similar costs (Table 2). PR is
significantly less expensive than either PPV or SB.
Moreover, as PR can be performed in the office,
avoiding the significant inherent expenses associ-
ated with hospital-based surgical procedures can
further reduce costs. Conversely, due to its higher
failure (and redetachment) rate, primary PR may
RETINAL DETACHMENT: MANAGEMENT TRENDS 61

TABLE 2 vitrectomy in specific cases of RRD, results have

Cost for the Repair of Rhegmatogenous Retinal Detachment
Physician Facility
Method Fee* Fee*
Pars plana vitrectomy $813.58 $643
CPT 67036
Pars plana vitrectomy $1,420.69 $731
with membrane strip
CPT 67038
Pars plana vitrectomy $1,035.37 $1,015
with focal endolaser
CPT 67039
Scleral buckle $1,058.14 $731
CPT 67107
Scleral buckle with $1,448.69 S1,015
pars plana vitrectomy
CPT 67108
*
2004 Maximum reimbursement figures based on national
Medicare averages.
require more expensive reoperation(s). Ultimately,
a cost-utility analysis of the three surgical procedur-
es—with long-term follow-up taking into consider-
ation the cost of reoperations—might be required
to assess which of the three procedures (or
combination of procedures) is the most effective
surgical approach from a health care economic
analysis perspective.
Regardless of the specific surgical approach, the
significant cost of RRD repair is, in part, due to the
high cost of emergent surgery. RRD is a surgical
emergency to prevent progression to macular de-
tachment, a negative predictor of post-operative
visual acuity. In an outcome and cost analysis study
of scheduled (delayed) vs. emergent SB surgery for
patients with RRD with an attached macula, Hartz
et al demonstrated that none of the patients with an
attached macula experienced macular involvement
while awaiting scheduled surgery.60 Moreover, they
found no difference between emergent and sched-
uled patients in ocular or systemic complications,
rate of reattachment, or visual outcome. Conversely,
a greater cost was incurred for the patients having
emergent surgery due to difference in pay scales for
support personnel. This suggests that emergent
surgery may not be necessary for many patients with
RRD, which may reduce the cost of repairing retinal
detachments.
COMPARATIVE OUTCOME
Despite the variety of surgical techniques, the
management of RRD remains a challenge. At pre-
sent, there are few randomized, controlled clinical
trials directly comparing SB and PPV. Although
published studies have compared buckling to
not consistently demonstrated the superiority of
a single method. In several retrospective studies
comparing SB with PPV for primary RRD, both
approaches appear to have similar efficacies. Afrashi
et al compared conventional SB with PPV using
silicone oil tamponade in patients with RRD with
multiple breaks, and reported primary retinal
reattachment success rates of 80% with SB and
91% with PPV.2 Miki et al found that initial (92%)
and final (100%) anatomical success rates were the
same for superior RRD treated with SB or PPV.88
Similarly, Oshima et al reported that both SB and
PPV achieve favorable anatomic and visual outcome
in the majority of patients with primary macula-off
RRD (91% primary reattachment rate).93 However,
they further observed that PPV may be more
effective than SB for achieving early visual rehabil-
itation in cases complicated by poor preoperative
vision, ocular hypotony, and prolonged macular
detachment, suggesting that PPV may be more
appropriate for a subset of patients with RRD. Of
note, Wolfensberger recently reported that com-
plete foveal reattachment after macula-off RRD
occurs without delay after PPV, but subfoveal fluid
may persist subclinically for several months in these
patients treated with SB.133 However, the signifi-
cance of the subfoveal fluid, and whether it has an
impact on long-term visual acuity, remains unclear.
The use of combined surgical approaches has also
been an active area of investigation. However, again,
results from multiple clinical studies have been
conflicting. In a prospective, randomized study,
Stangos et al recently reported that PPV is as
effective as PPV with an additional encircling buckle
for pseudophakic patients with RRD, and has the
benefit of fewer intraoperative and postoperative
complications.114 Sharma et al also reported that
successful reattachment of primary RRD with in-
ferior breaks can be achieved with PPV alone, and
that supplementary SB is unnecessary.110 A similar
conclusion was drawn in a retrospective study by
Wickham et al.129
Conversely, Tewari et al, in a randomized trial of
44 eyes with unseen retinal breaks, reported no
statistically significant differences in either reattach-
ment rates or visual outcomes between a 360 SB
and a combined procedure of SB with PPV,119
suggesting that SB alone is an effective technique in
the primary management of uncomplicated RRD
with unseen retinal breaks (if the media is clear).
Similarly, in a retrospective study, Halberstadt et al
observed that the anatomical and functional out-
come of primary retinal reattachment surgery for
patients with phakic or pseudophakic eyes was the
same for SB alone or SB combined with PPV.58
62 Surv Ophthalmol 53 (1) January--February 2008
However, a prospective, non-randomized clinical
study by Devenyi et al concluded that a combined
approach of SB with PPV offers significant benefits
over SB alone, including improved success rates
(primary reattachment of combined surgical
approach 100%).36 In this study, however, reattach-
ment rates with a single approach (SB or PPV) were
not assessed. Moreover, increased complications
associated with the combined surgical approach
remains unclear. It is tempting to speculate that the
complication rate of combined procedures may
approach the summation of that observed for each
procedure alone.
We are continuing to examine new indications for
pneumatic retinopexy as a safe, minimally invasive
procedure. In a multicenter, randomized trial pub-
lished in 1989, Tornambe et al showed that PR and SB
had statistically similar anatomic results in eyes with
superior breaks and without PVR.123 In fact, when
postoperative photocoagulation or cryotherapy was
considered, success rates were virtually identical
between the groups. Moreover, the PR group had
less morbidity and better postoperative visual acuity;
a two-year follow-up study confirmed that long-term
results were comparable to standard SB therapy.
However, in a prospective, randomized, clinical trial
of 20 eyes, Mulvihill et al demonstrated a lower final
reattachment rate with PR compared to SB (90% vs.
100%, respectively).90 Similarly, in a retrospective
study, Han et al found that PR resulted in equivalent
final visual outcome and reattachment rate with SB,
but only after a significantly higher reopertion rate,59
emphasizing the importance of careful selection of
appropriate patients for PR.
As PR has gained acceptance as a therapy for RRD,
several studies suggest that situations for which the
procedure was previously contraindicated may now
be appropriate. Kleinmann et al conducted a retro-
spective study comparing 44 eyes divided into three
groups undergoing PR, including one group with
vitreoretinal abnormalities and a second group with
pseudophakic or aphakic status, both classic relative
contraindications to the procedure.70 Single-proce-
dure anatomic success rates were at least 64%, and
final success rates were at least 91% in each group.
Although phakic eyes without vitreoretinal abnor-
malities showed a higher rate of single-procedure and
final reattachment, the difference was not significant.
Studies have provided anything but definitive data,
however. Kovacevic demonstrated that 50% of
aphakic or pseudophakic eyes redetached postoper-
atively, and greater than 10% developed PVR, an
infrequently reported complication of PR.74 As a re-
sult, some physicians remain reluctant to make PR
common practice. In a survey of Vitreous Society
members conducted by Wild et al, SB was favored over
SODHI ET AL
PR by a ratio of 2:1 in almost every situation, except
when 1) an operating room was not available; or 2)
the patient was uninsured.130
Prospective, Randomized Clinical Trials
Three recent prospective, randomized clinical
trials may help provide further insight as to which
surgical approach(es) are best suited for optimal
primary treatment of RRD (Table 3). In a pro-
spective, randomized, multicenter clinical trial (the
Pseudophakic and Aphakic Retinal Detachment
[PARD] Study), Ahmadieh et al compared the
anatomic and visual results and complications of
conventional SB versus PPV for management of
pseudophakic and aphakic retinal detachment.3
Two hundred twenty-five eyes of 225 patients with
pseudophakic or aphakic RRD were assigned ran-
domly either to conventional SB (126) or PPV
without SB (99) and followed up for 6 months.
Outcome measures included visual results, retinal
reattachment rate, proliferative vitreoretinopathy,
macular pucker, cystoid macular edema, choroidal
detachment, intraocular pressure, extraocular mus-
cle dysfunction, and anisometropia. Patients in the
SB group had 28% greater likelihood of anatomic
success compared with those in the vitrectomy
group, but these results were not statistically
significant. Proliferative vitreoretinopathy was the
main cause of anatomic failure in both groups. Six
months after surgery, 12.8% of eyes in the buckle
group and 11.3% of eyes in the vitrectomy group
achieved visual acuity of 20/40 or better. Again, the
difference between the two groups was not statisti-
cally significant. There were also no statistically
significant differences in rates of complications. The
authors ultimately concluded that SB and PPV
without an encircling band have comparable results
in pseudophakic and aphakic RD and that the
choice of surgical technique depends on patient
compliance, cost of surgery, experience and capa-
bility of surgeons, and availability of appropriate
instrumentation.
Sharma et al also recently published a randomized
prospective clinical trial to compare PPV without SB
versus conventional SB surgery in pseudophakic
primary retinal detachment (PPRD) in terms of
anatomic attachment rate, functional outcome, and
complications.112 Fifty consecutive eyes of 50 pa-
tients with PPRD were randomized into two groups,
with 25 patients treated with SB and 25 with PPV and
followed up for up to 6 months. A primary
reattachment rate of 76% (19 retinas) was obtained
in the SB group compared to 84% in patients in the
PPV group. This difference, however, was not
RETINAL DETACHMENT: MANAGEMENT TRENDS
TABLE 3
Prospective Randomized Clinical Trails Comparing Scleral Buckling (SB) vs. Pars Plana Vitrectomy (PPV)
Clinical Trail Description
Pseudophakic and aphakic 225 eyes of 225 patients
retinal detachment with pseudophakic or
(PARD) Study aphakic RRD were
(Achmadieh et al, 20053) assigned randomly
either to conventional
SB (126) or PPV without
SB (99) and followed up
for 6 months
PPV without SB versus 50 consecutive eyes of
conventional SB surgery 50 patients with PPRD
in pseudophakic primary were assigned randomly
retinal detachment either to conventional
(PPRD) Study SB (25) or PPV without
(Sharma et al, 2005112) SB (25) and followed up
for 6 months
Anatomical and functional 150 eyes of 150 patients
outcomes of SB surgery with pseudophakic RD
with that of PPV in the and stage B PVR or less
treatment of primary RRD were randomized to
either SB surgery (75)
or primary PPV (75)
and followed up for
1 year
Scleral Buckling Versus 45 surgeons from 25
Primary Vitrectomy centers in five
in Rhegmatogenous European countries
Retinal Detachment recruited 664 patients
(SPR) Study (326 PPV and 338 SB),
including 257
pseudophakic and
407 phakic eyes, during
a 5-year period
statistically significantly and the final anatomic
reattachment rate was 100% in both groups. The
causes of initial failure in the SB group were PVR in
five eyes (20%) and open or missed breaks in one
eye (4%). The causes of initial failure in the PPV
group were open or missed breaks in three eyes
(12%) and PVR in one eye (4%). Best corrected
visual acuity was initially better in the SB group at 2
weeks (suspected to be secondary to the optical
problems created by the C3F8 gas bubble in the PPV
63
Outcome Measures Conclusion
visual results, retinal SB and PPV without
reattachment rate, an encircling band
proliferative have comparable results
vitreoretinopathy, in pseudophakic and
mascular pucker, aphakic RD; the choice
cystoid mascular of surgical technique
edema, choroidal depends on patients
detachment, intraocular compliance, cost
pressure, extraocular of surgery, experience
muscle dysfunction, and capability of
and anisometropia surgeons, and availability
of appropriate
instrumentation
anatomic attachment PPV without buckling is
rate functional an effective treatment
outcome and for PPRD and may result
complications in better intermediate
term visual outcomes
than conventional SB
break diagnosis, PPV offers potential
operating time, advantages over SB
intraoperative surgery in the treatment
and postoperative of pseudophakic RD,
complications, including less operating
retinal reattachment rate time, accurate diagnosis
for single as well of breaks, higher
as multiple surgeries, reattachment rate
axial length changes, with a single surgery, and
and best-corrected no postoperative
visual acuity axial length changes;
however, retinal
reattachment rate with
multiple surgeries and
final visula acuity at
1 year were similar for
SB surgery and PPV
Not yet published Not yet published
group), but was two lines better in the PPV group at
end of 6 months (p 5 0.03); further follow up was
not provided. The authors concluded that PPV
without buckling is an effective treatment for PPRD
and results in better intermediate term visual
outcomes than conventional SB.
In a third prospective, randomized clinical trial,
Brazitikos et al also recently compared the anatom-
ical and functional outcome of SB surgery with that
of PPV in the treatment of primary RRD.12 One
64 Surv Ophthalmol 53 (1) January--February 2008
hundred fifty eyes of 150 patients with pseudo-
phakic RD and PVR stage B or less were randomized
to either SB surgery (75 eyes) or primary PPV (75
eyes). Postoperative follow-up was 1 year. Outcome
measures included break diagnosis, operating time,
intraoperative and postoperative complications,
retinal reattachment rate for single as well as
multiple surgeries, axial length changes, and best
corrected visual acuity at 1 year after surgery. They
found that the number of eyes that were diagnosed
with additional breaks inter-operatively was higher
and mean operating time was significantly less in the
PPV group. With a single surgery, the retina was
reattached in 62 eyes (83%) in the SB surgery group
and in 71 eyes (94%) in the PPV group. With
subsequent surgeries, final anatomical reattachment
was achieved in 71 cases in the SB surgery group and
in 74 cases in the PPV group. Mean final best
corrected visual acuity (logMAR) was not signifi-
cantly different between the two groups. They
concluded that primary PPV offers potential advan-
tages over SB surgery in the treatment of pseudo-
phakic RD, including less operating time, accurate
diagnosis of breaks, higher reattachment rate with
a single surgery, and no postoperative axial length
changes. Retinal reattachment rate with multiple
surgeries and final visual acuity at 1 year were similar
for SB surgery and PPV.
These three studies suggest that a high powered
clinical trial will ultimately be required to address
the question as to which procedure, SB or PPV, is
a better therapeutic approach for RD. In this regard,
the Scleral Buckling Versus Primary Vitrectomy in
Rhegmatogenous Retinal Detachment (SPR) Study
is the first prospective multi-centered comparison of
scleral buckling to primary vitrectomy in RRD.61
This study includes 45 surgeons from 25 centers in
five European countries. During the 5-year recruit-
ment period (8/1998 to 7/2003), 664 patients (326
PPV and 338 SB) were recruited, including 257
pseudophakic and 407 phakic eyes. The results of
this study are anticipated later this year and are
expected to provide answers to several questions
regarding the comparable efficacy of these two
procedures. Additional prospective randomized
clinical trials comparing the efficacy of combined
procedures or of new procedures (e.g., transcon-
junctival sutureless vitrectomy) will likely be needed
to further assess the relative effectiveness of each
surgical approach for treatment of RRD.
Conclusions
Identifying which surgical approach(es) are best
suited under specific circumstances for optimal
SODHI ET AL
treatment of RRD will necessitate further prospective,
randomized clinical trials. These trials should include
an evaluation of surgical interventions from multiple
perspectives, not just traditional clinical ones. In
addition to anatomic outcomes, long-term clinical
outcomes should include visual acuity, refractive
outcomes, and the need for secondary procedures
(for persistent or recurrent retinal detachment as
well as for other complications including cataracts,
glaucoma, strabismus etc.). Patient outcomes will
need to address patient pain and discomfort, time off
work, perceived quality of vision, and other (sub-
jective and objective) symptoms (e.g., related to
anisometropia). Some of these measures can be
studying using validated quality of life questionnaires
such as the QOL National Eye Institute Visual
Function Questionnaire 25 (VFQ-25).84 Such out-
comes should be assessed both in the early post-
operative phase as well as with longer follow-up.
Provider outcomes should also be addressed, which
should include an evaluation of postoperative follow-
up care and costs in addition to surgical time. Finally,
societal outcomes should be examined, including
procedural cost, cost-effectiveness, and cost-utility of
intervention. It is unlikely that a single clinical trial
will be able to address all of these issues, but well-
designed, randomized clinical trials may help
determine under which circumstances a specific
surgical approach for RRD may be most effective.
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The authors reported no proprietary or commercial interest in
any product mentioned or concept discussed in this article.
Reprint address: James T. Handa, MD, 1550 Orleans St, Suite
144, Baltimore, MD 21287-9277.