It is probable that the per capita incidence of retinal detachment has decreased over the past three decades. The replacement of intracapsular cataract surgery, first by extracapsular surgery and then by phacoemulsification with endocapsular intraocular lenses, has certainly contributed to the decline. The widespread use of indirect ophthalmoscopy and retinopexy for prophylaxis of retinal breaks has probably had a major impact as well. It is also likely that the increased use of protective eyewear has made a contribution.

The increasing number of retinal specialists per capita coupled with fewer detachments per patient-year, variable pathology, and significantly more treatment options has virtually guaranteed that the treatment of retinal detachment will never move to an evidence-based paradigm because of the statistical complexity. Therapeutic options include scleral buckling, vitrectomy, and pneumatic retinopexy. Gas choices include air, C₃F₈, and SF₆. Buckle options include sponges versus “hard” silicone, drainage versus nondrainage, encircling versus segmental, radial versus circumferential, etc. Retinopexy choices include cryotherapy versus laser (transscleral or laser indirect ophthalmoscope) versus diathermy. Many of these therapies are used in combination, making the analysis even more complex.

Laser is preferred to cryotherapy for prophylactic retinopexy because there is less pain and potentially less proliferative vitreoretinopathy (PVR). Low to moderate intensity confluent lesions with fewer rows are preferred by the authors over the very common method of using many rows of heavy, spaced-out lesions. Many authors recommend treatment only if the retinal breaks are symptomatic (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). Relying on the patient can be effective in a population of highly educated people but is less reliable in patients having less education and more socioeconomic problems. Large breaks are typically more significant than small breaks. Retinal detachment in the fellow eye or another location in the same eye or a family history of detachment is a relative indication for treatment. Patients for whom cataract surgery is planned, athletes, or certain careers with risk of high G-forces or non-availability of care may indicate the need for prophylactic treatment as well. Retinal breaks outside lattice are more significant than breaks inside lattice. Superior breaks are probably more significant than inferior breaks. Pigment around breaks does not indicate adherence to the retinal pigment endothelium but does indicate chronicity.

Laser can be used to “wall-off,” better termed “laser delimiting,” a retinal detachment which is small enough that a triple row of laser will not significantly impair the visual field. On occasion, laser-delimited detachments will spontaneously reattach. Laser confinement of relatively small retinal detachments has remarkably good long-term results and is almost certainly underutilized because of habit and economics.