43

QUESTION

DO CHRONIC RHEGMATOGENOUS RETINAL DETACHMENTS NEED SURGICAL REPAIR?

Charles C. Wykoff, MD, PhD
Harry W. Flynn, Jr., MD
Nidhi Relhan Batra, MD

Rhegmatogenous retinal detachment (RRD) is a frequent clinical challenge affecting approximately 1/200 people over the course of a lifetime.¹ An RRD is one of the most common indications for vitreoretinal surgery and such surgical repair is one of the most cost-effective practices in the treatment of vitreoretinal disorders.^2,3 Despite this, some asymptomatic chronic RRDs may be observed and may not progress.^4,5

Two key factors should be considered when determining if serial observation may be a reasonable approach to the management of a chronic RRD.

First, while there are many points to consider in the patient history, perhaps the most important is the presence or absence of symptoms. In many fields of medicine, patients with the same clinical problem, one symptomatic and the other asymptomatic, may be treated quite differently; for example, in the settings of cholelithiasis where the presence of symptoms may indicate intervention that otherwise may have been deferred. While self-evident, it is worth recognizing that in the absence of current or past symptoms, it is not possible to make a patient symptomatically better. In the setting of an individual without the expected capacity to recognize or report symptoms, however, this factor is less important and possibly irrelevant. Asymptomatic RRD suggests an absence of tractional forces on the retinal break or lack of an acute posterior vitreous detachment (PVD). Published reports indicate that an asymptomatic RRD can sometimes progress slowly, but good anatomic and visual outcomes can still be achieved with surgical intervention if ultimately necessary (Table 43-1).^6–10 For example, Kothari and colleagues ¹⁰ reported 3 patients with chronic RRDs associated with subretinal bands successfully repaired with good visual outcomes.

Second, ophthalmoscopic characteristics are important to consider when determining appropriate management. For example, a bullous, fovea-threatening, superior RRD in the setting of an acute PVD is a clear indication for urgent surgical repair. In contrast, an asymptomatic, shallow, peripheral RRD secondary to an atrophic hole within an area of lattice degeneration, lack of PVD, thinned detached retina with intraretinal cysts and demarcation lines, in a non-myopic patient may not require any surgical intervention (Figures 43-1 through 43-3). Other anatomic factors to consider include macula status, presence of a retinal dialysis, and lens status. Preexisting poor function of the macula in an eye with a chronic macula-involving RRD may be observed in select circumstances. An asymptomatic chronic RRD in an eye with an inferior retinal dialysis may not progress for many years since subretinal fluid may accumulate very slowly.⁴ Nonprogression of chronic asymptomatic RRD has been well-documented in both phakic and aphakic eyes.^11,12

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