What is the recommended treatment for retinal detachment?

Treatment of Retinal Detachment

Retinal detachment requires immediate surgical intervention, with more than 95% of uncomplicated cases successfully repaired, and the specific surgical approach—including laser photocoagulation, cryotherapy, scleral buckle, vitrectomy, or combination techniques—depends on the type and extent of detachment. 1, 2

Surgical Management Algorithm

For Symptomatic Retinal Breaks (Horseshoe/Flap Tears)

• Immediate treatment is mandatory because at least 50% of untreated symptomatic retinal breaks with persistent vitreoretinal traction will progress to clinical retinal detachment. 1, 2
• Prompt creation of a chorioretinal adhesion around symptomatic tears reduces the risk of retinal detachment to less than 5%. 1, 2
• Treatment options include laser photocoagulation or cryotherapy to create a chorioretinal adhesion around the break, with treatment extending to the ora serrata if the tear cannot be completely surrounded. 2

For Established Retinal Detachment

• Early surgical repair is critical because the rate of successful reattachment is higher and visual results are dramatically better when repaired before the detachment involves the macula. 1, 2
• Surgical options include scleral buckle, pars plana vitrectomy, tamponading agents, or combination approaches depending on the clinical scenario. 2, 3
• Currently, more than 95% of uncomplicated retinal detachments can be successfully repaired, although more than one procedure may be required. 1

For Tractional Retinal Detachment Threatening or Involving the Macula

• Immediate vitrectomy is indicated for any tractional retinal detachment threatening or involving the macula, with anatomical success rates exceeding 90%. 4
• Macula-on detachments have dramatically better visual outcomes than macula-off detachments, making timing absolutely critical. 4
• Do not attempt observation or anti-VEGF monotherapy as first-line treatment when vitrectomy is feasible, as this delays definitive treatment and worsens outcomes. 4

Asymptomatic Lesions That Generally Do Not Require Treatment

• Asymptomatic operculated holes and atrophic round holes rarely lead to retinal detachment, with zero progression to detachment in 74 eyes followed for up to 11 years. 1
• Atrophic round holes within lattice lesions accompanied by minimal subretinal fluid and no posterior vitreous detachment do not require treatment. 1
• Small asymptomatic peripheral retinal detachments (subclinical detachments) secondary to retinal holes in areas of lattice degeneration have a very low likelihood of progression with observation alone. 1

Critical Timing Considerations

The window for optimal intervention is narrow. Symptomatic horseshoe tears require prompt treatment because the laser- or cryotherapy-induced chorioretinal adhesion may not be firm or complete for up to 1 month following treatment. 1

When Media Opacity Prevents Examination

• B-scan ultrasonography must be performed to detect retinal tears or detachment when fundoscopic examination is not possible due to media opacity. 2, 5

Follow-Up Protocol

Initial Post-Treatment Monitoring

• First follow-up visit at 1-2 weeks after treatment to assess treatment adequacy. 1, 2
• Indirect ophthalmoscopy and scleral depression at 2-6 weeks to determine the adequacy of the chorioretinal scar, especially around the anterior boundary of the tear. 1, 2
• If the tear and accompanying subretinal fluid are not completely surrounded by the chorioretinal scar, additional treatment must be administered. 1

Long-Term Surveillance

• Between 5% and 14% of patients with an initial retinal break will develop additional breaks during long-term follow-up, making continued monitoring essential. 1, 2
• Pseudophakic patients are more likely to require retreatment or develop new breaks. 1
• Younger myopic patients with lattice degeneration and holes need regular follow-up visits to monitor for subclinical retinal detachments that may slowly enlarge. 1, 2

For Acute Posterior Vitreous Detachment Without Breaks

• Patients presenting with acute posterior vitreous detachment and no retinal breaks have approximately 2% chance of developing retinal breaks in the following weeks. 1, 2
• Selected patients, particularly those with any degree of vitreous pigment, vitreous or retinal hemorrhage, or visible vitreoretinal traction, should return for a second examination within 6 weeks following symptom onset. 1, 6

Common Pitfalls and How to Avoid Them

Delayed Diagnosis

• All patients at increased risk must be instructed to contact their ophthalmologist immediately if they experience new flashes, floaters, peripheral visual field loss, or decreased visual acuity. 1, 2
• Between 8% and 22% of patients with acute posterior vitreous detachment symptoms have a retinal tear at initial examination. 6

Inadequate Treatment Coverage

• Retinal detachments may occur despite appropriate therapy because traction can pull the tear from the treated area, especially with larger breaks or bridging retinal blood vessels. 1
• At any postoperative visit, additional treatment should be considered if subretinal fluid has accumulated beyond the edge of treatment. 1

Underestimating Progression Risk

• Approximately 5% of eyes with asymptomatic horseshoe tears progress to retinal detachment, but symptomatic horseshoe tears have at least a 50% risk without treatment. 1
• Traumatic dialyses and tears along the vitreous base are managed similarly to symptomatic tears. 1

Special Clinical Scenarios

Subclinical Retinal Detachments in Lattice Degeneration

• Prophylactic or interventional treatment should be considered when detachments are documented to become symptomatic, increase in size, or show other signs of progression. 1, 2
• In one analysis of 423 eyes with lattice degeneration followed for nearly 11 years, only 3 eyes developed clinical retinal detachments. 1

Proliferative Changes

• Proliferation of epiretinal membrane (macular pucker) has been occasionally observed following treatment for a retinal break, but the method of creating a chorioretinal adhesion may be unrelated to the incidence of postoperative macular pucker. 1