Traditional Versus Recent Approaches to Fovea-Sparing RRD Repair
Foveal involvement in rhegmatogenous retinal detachment (RRD) has consistently been identified as one of the most important prognostic factors correlating with postoperative visual outcome.1–4 Throughout the 20th century, literature on the subject suggested a correlation between time to surgery and postoperative visual acuity (VA) and anatomic success. Traditional thinking prompted emergent surgery to preserve the fovea in fovea-sparing RRDs. More recently, animal models have been used to demonstrate potentially irreversible changes occurring within minutes of retinal detachment (RD).5–8 The timing of such pathophysiologic processes suggests that, ideally, surgical repair of RRD would be performed before foveal detachment, and it logically follows that time from presentation to surgical repair may correlate with ultimate outcomes.
James C. Major Jr.
Alexander M. Rusakevich
Interestingly, however, despite the clinical concern for fovea detachment while awaiting surgical repair, the progression of subretinal fluid (SRF) into the fovea appears to be rare in most recent reported case series, occurring in 0.5% (one of 199) of fovea-on eyes in one study9 and 1.1% (10 of 930) in another study.10 Even when SRF does eclipse the fovea, however, visual outcomes can still be preserved; Kontos et al. reported that visual outcomes were not compromised after progression of 10 cases to fovea-off status out of a total of 930 fovea-sparing RRD, although two of these eyes did lose one Snellen line.10
Somewhat counter-intuitively, these recent retrospective studies have documented little correlation of time from fovea-sparing RRD diagnosis to surgical repair with outcomes.9–13 In a seminal series of 199 fovea-sparing RRDs managed with scleral buckle (SB), Wykoff et al. found no statistically significant difference in visual or anatomic outcomes for eyes operated within 3 days of initial evaluation.9 Similarly in another study involving 66 macula-sparing RRDs treated with SB, pars plana vitrectomy (PPV), or PPV with SB (PPV/SB), eyes operated within 24 hours of presentation did not differ in visual or anatomic success from those operated after 24 hours.13 Such retrospective analyses carry inherent biases, including the clinicians' judgement as to which patients may have been rushed to surgery compared to those determined stable for planned surgery on the next convenient operative day. Nevertheless, these studies are invaluable guides for clinicians in the setting of managing what has traditionally been regarded as a potential surgical emergency with medical-legal implications.
Current Retrospective Data: Urgent but Not Necessarily Emergent
In the largest fovea-sparing RRD case series to date, Lee et al. investigated outcomes following primary repair of fovea-sparing RRDs managed with any surgical approach: pneumatic retinopexy (PR), SB, PPV, or PPV/SB in the context of a large, retina-only, metropolitan practice. The primary focus was to evaluate the impact of perioperative factors, including time to surgery, on anatomic and visual outcomes for 423 eyes.14
Eight predefined clinical factors were evaluated for association with time to surgery: lens status, duration of RRD symptoms, number of quadrants involved, RRD posterior extent, RRD extent closest to the fovea, number of retinal breaks, quadrants with retinal breaks, and initial evaluation on Friday or Saturday versus Sunday through Thursday. Clinical history and examination findings play significant roles in determining time to surgical repair of fovea-sparing RRD. The current study identified three clinical factors that correlated significantly with a shorter time from presentation to surgery: shorter symptom duration, superior RRD location, and extension of SRF into the macula.14 Prior studies have similarly reported faster time to surgery for superior and temporal RRDs compared to inferior and nasal RRDs.9,11
Thirteen predefined demographic and clinical factors were evaluated for association with both visual and anatomic outcomes: age, gender, lens status, preoperative VA, lifetime contralateral RRD, RRD symptom duration, time from initial evaluation to surgical repair, single operation anatomic success, number of quadrants involved, posterior RRD extent, RRD extent closest to the fovea, number of retinal breaks, quadrants with retinal breaks, and surgery on Saturday or Sunday versus Monday through Friday. Among all eyes, surgeries performed Monday through Friday were more likely to achieve single operation anatomic success compared to surgeries performed on Saturday or Sunday.14
Traditionally, fovea-sparing RRD has been a clinical indication for emergent surgical intervention in attempt to prevent foveal detachment and preserve final VA.15 To the contrary, within the inherent biases of the clinical algorithm employed, the current study found that time from diagnosis of fovea-sparing RRD to surgical repair did not affect anatomic or visual success. The previously mentioned studies involving fovea-sparing RRDs have drawn similar conclusions.9–13
Emergent surgeries may incur additional risks due to reduced resources, fewer staff, surgeon fatigue, and lack of medical clearance for surgery and anesthesia.16–18 Indeed, in the current series, surgeries performed Monday through Friday were more likely to achieve single-operation anatomic success than those performed on Saturday or Sunday, although any substantial conclusion from this data is restricted, both by the limited number of cases and the higher proportion of PR interventions among weekend cases compared to cases performed during the week. Notably, however, studies from other surgical subspecialties have also demonstrated inferior surgical outcomes for operations performed on Saturday or Sunday.19–22 Although the current study appears to corroborate published literature in other surgical fields, interpretation of the current data should be tempered by the inherent limitations. Additional studies, ideally prospective, are needed to better understand patient outcomes related to timing of surgical intervention for RRD.
Appropriately scheduled RRD surgery benefits both patients and medical staff by providing more time for coordination of social and psychological support and allowing the use of familiar surgical resources, respectively. Concurrently, the health care system benefits from decreased expenditure, as scheduled RRD surgeries have been reported to cost substantially less than emergent interventions.17 While awaiting RRD surgery, some authors have advocated short-term positioning, ocular immobilization, bilateral patching, and bed rest to prevent RRD progression.23–28
In summary, the current retrospective analysis of a large database of fovea-sparing RRDs, confirmed by individual patient image analysis, identified three clinical factors that appeared to prompt faster intervention — shorter symptom duration, superior location, and posterior extension into the macula — all likely stemming from the surgeons' desire to preserve fovea-on status. Within the context of the current biases and clinical approach employed, time to surgical repair did not appear to impact visual or anatomic outcomes, preoperative VA and single operation success correlated with visual outcomes, and surgeries performed Monday through Friday correlated with anatomic outcomes.
- Burton TC, Lambert RW Jr, . A predictive model for visual recovery following retinal detachment surgery. Ophthalmology. 1978;85(6):619–625. doi:10.1016/S0161-6420(78)35636-0 [CrossRef]
- Tani P, Robertson DM, Langworthy A. Rhegmatogenous retinal detachment without macular involvement treated with scleral buckling. Am J Ophthalmol. 1980;90(4):503–508. doi:10.1016/S0002-9394(14)75019-6 [CrossRef]
- Wilkinson CP. Visual results following scleral buckling for retinal detachments sparing the macula. Retina. 1981;1(2):113–116. doi:10.1097/00006982-198101020-00007 [CrossRef]
- Salicone A, Smiddy WE, Venkatraman A, Feuer W. Visual recovery after scleral buckling procedure for retinal detachment. Ophthalmology. 2006;113(10):1734–1742. doi:10.1016/j.ophtha.2006.03.064 [CrossRef]
- Geller SF, Lewis GP, Fisher SK. FGFR1, signaling, and AP-1 expression after retinal detachment: Reactive Müller and RPE cells. Invest Ophthalmol Vis Sci. 2001;42(6):1363–1369.
- Nakazawa T, Matsubara A, Noda K, et al. Characterization of cytokine responses to retinal detachment in rats. Mol Vis. 2006;12:867–878.
- Iandiev I, Uckermann O, Pannicke T, et al. Glial cell reactivity in a porcine model of retinal detachment. Invest Ophthalmol Vis Sci. 2006;47(5):2161–2171. doi:10.1167/iovs.05-0595 [CrossRef]
- Hollborn M, Francke M, Iandiev I, et al. Early activation of inflammation- and immune response-related genes after experimental detachment of the porcine retina. Invest Ophthalmol Vis Sci. 2008;49(3):1262–1273. doi:10.1167/iovs.07-0879 [CrossRef]
- Wykoff CC, Smiddy W, Mathen T, Schwartz SG, Flynn HW Jr., Shi W. Fovea-sparing retinal detachments: Time to surgery and visual outcomes. Am J Ophthalmol. 2010;150(2):205–210.e2. doi:10.1016/j.ajo.2010.03.002 [CrossRef]
- Kontos A, Williamson TH. Rate and risk factors for the conversion of fovea-on to fovea-off rhegmatogenous retinal detachment while awaiting surgery. Br J Ophthalmol. 2017;101(8):1011–1015. doi:10.1136/bjophthalmol-2016-309178 [CrossRef]
- Ho SF, Fitt A, Frimpong-Ansah K, Benson MT. The management of primary rhegmatogenous retinal detachment not involving the fovea. Eye (Lond). 2006;20(9):1049–1053. doi:10.1038/sj.eye.6702083 [CrossRef]
- Ehrlich R, Niederer RL, Ahmad N, Polkinghorne P. Timing of acute macula-on rhegmatogenous retinal detachment repair. Retina. 2013;33(1):105–110. doi:10.1097/IAE.0b013e318263ceca [CrossRef]
- Lai MM, Khan N, Weichel ED, Berinstein DM. Anatomic and visual outcomes in early versus late macula-on primary retinal detachment repair. Retina. 2011;31(1):93–98. doi:10.1097/IAE.0b013e3181de55f0 [CrossRef]
- Lee IT, Lampen SI, Wong TP, Major JC Jr., Wykoff CC. Fovea-sparing rhegmatogenous retinal detachments: Impact of clinical factors including time to surgery on visual and anatomic outcomes. Graefes Arch Clin Exp Ophthalmol. 2019;257(5):883–889. doi:10.1007/s00417-018-04236-4 [CrossRef]
- The repair of rhegmatogenous retinal detachments. Ophthalmology. 1990;97(11):1562–1572. doi:10.1016/S0161-6420(90)32376-X [CrossRef]
- Hartz AJ, Burton TC, Gottliev MS, et al. Outcome and cost analysis of scheduled versus emergency scleral buckling surgery. Ophthalmology. 1992;99(9):1358–1363. doi:10.1016/S0161-6420(92)31794-4 [CrossRef]
- Frimpong-Ansah K, Kirkby GR. Arrangements for the management of urgent retinal detachments in the United Kingdom and Eire in the year 2000: Results of a survey. Eye (Lond). 2002;16(6):754–760. doi:10.1038/sj.eye.6700326 [CrossRef]
- Rojas J, Fernández I, Pastor JC, Gómez-Ulla F, Piñero A. [Urgent retinal detachment management by the National Health System of Spain. Project Retina 2]. Arch Soc Espanola Oftalmol. 2007;82(5):279–284.
- Goldstein SD, Papandria DJ, Aboagye J, et al. The ‘weekend effect’ in pediatric surgery - increased mortality for children undergoing urgent surgery during the weekend. J Pediatr Surg. 2014;49(7):1087–1091. doi:10.1016/j.jpedsurg.2014.01.001 [CrossRef]
- Zapf MAC, Kothari AN, Markossian T, et al. The ‘weekend effect’ in urgent general operative procedures. Surgery. 2015;158(2):508–514. doi:10.1016/j.surg.2015.02.024 [CrossRef]
- Desai V, Gonda D, Ryan SL, et al. The effect of weekend and after-hours surgery on morbidity and mortality rates in pediatric neurosurgery patients. J Neurosurg Pediatr. 2015;16(6):726–731. doi:10.3171/2015.6.PEDS15184 [CrossRef]
- Tadisina KK, Chopra K, Singh DP. The ‘weekend effect’ in plastic surgery: Analyzing weekday versus weekend admissions in body contouring procedures from 2000 to 2010. Aesthet Surg J. 2015;35(8):995–998. doi:10.1093/asj/sjv088 [CrossRef]
- Algvere P, Rosengren B. Immobilization of the eye. Evaluation of a new method in retinal detachment surgery. Acta Ophthalmol (Copenh). 1977;55(2):303–316. doi:10.1111/j.1755-3768.1977.tb01312.x [CrossRef]
- Lean JS, Mahmood M, Manna R, Chignell AH. Effect of preoperative posture and binocular occlusion on retinal detachment. Br J Ophthalmol. 1980;64(2):94–97. doi:10.1136/bjo.64.2.94 [CrossRef]
- Johnston PB, Collins A, Maguire CJ, Logan WC. Ocular immobilization and its role in the management of superior retinal detachment. Trans Ophthalmol Soc U.K. 1982;102(pt 2):233–236.
- Lincoff H, Stopa M, Kreissig I. Ambulatory binocular occlusion. Retina. 2004;24(2):246–253. doi:10.1097/00006982-200404000-00010 [CrossRef]
- Foster WJ. Bilateral patching in retinal detachment: Fluid mechanics and retinal ‘settling’. Invest Ophthalmol Vis. Sci. 2011;52(8):5437–5440. doi:10.1167/iovs.11-7249 [CrossRef]
- de Jong JH, Vigueras JP, Simon TC, et al. Preoperative posturing of patients with macula-on retinal detachment reduces progression toward the fovea. Ophthalmology. 2017;124(10):1510–1522. doi:10.1016/j.ophtha.2017.04.004 [CrossRef]