LAUSR

Traditionally, the timing of rhegmatogenous retinal detachment (RRD) repair has been dependent on a binary assessment—whether the macula is detached or not. The rationale for this was based on the opinion that permanent functional damage occurred once the macula had detached, and therefore surgery should be performed within 24 h for a macula-on detachment [1, 2]. Patients presenting with a macula-off detachment have therefore been considered lower priority. Yorston et al. have recently reignited the debate on timing of surgery with their work on the effect of duration of macular detachment on visual recovery [3]. Although it continues to be standard practice to differentiate between macula-on (foveaon) and macula-off (fovea-off) detachment, it would be valuable to identify factors indicating a high risk of rapid progression of a macula-on RRD. The question we address here is whether the pre-operative status of the macula is still the most important factor determining the urgency of RRD repair. In 1982, Burton reported visual outcome after RRD repair was generally dependent on the duration of macular involvement. He found patients with macular detachment of ≤9 days duration were significantly more likely to regain a final vision of 6/15 or better than those with macula detachment of 10–19 days, or ≥20 days (p < 0.05) [1]. Later, Ross and Kozy reported equal visual outcomes whether RRD repair occurred 1–2 days, 3–4 days or 5–7 days after macular detachment [4]. Both of these studies were based on scleral buckling. This led to a policy of treating macula-off RRD with less urgency. However, several recent studies have yielded different results [5]. Williamson et al. examined 325 macula-off RRD patients with primary success and no proliferative vitreoretinopathy. They showed that final vision was significantly better if the retina was reattached 1–3 days after loss of vision compared to 4–6 days [6]. These findings were echoed by Yorston et al. in their UK database study of over 2000 eyes with macula-off RRD [3]. The most important modifiable risk factor to achieve better visual results was the duration of central visual loss (i.e. foveal detachment) being less than 72 h. It is also important to note that the difference in visual outcome between macula-on and macula-off RRD of less than 72 h is minimal, since those with macula involvement still achieve good (median 6/9) visual outcomes [6]. Furthermore, the risk of pre-operative conversion from maculaon at presentation to macula-off detachment has been shown to be low (0.5–0.11%) when surgery is performed within 24 h. The majority of cases that progress, occur within a few hours and have good visual outcomes [7]. The comparison of RRD displacement velocity during posturing and interruptions showed that superior RRD patient could benefit from pre-operative posturing [8]. In addition, intraoperative progression of macula-on RRD and macular displacement (as shown by autofluorescence vessel shift) after pars plana vitrectomy with gas can occur, and may be more common than is currently recognised [9]. If the RRD is liable to convert from maculaon to macula-off during surgery, it is questionable that preoperative foveal attachment should be the main determinant of surgical prioritisation. A careful assessment of RRD characteristics at presentation is important to determine the speed of RRD progression. In Kontos’ study assessing change in macular status between diagnosis and surgery, 10/930 patients progressed from macula-on to macula-off RRD, and the majority (9/10) had superotemporal detached retinal breaks. Only one case had superonasal RRD resulting in macula-off RRD. All ten patients regained 6/12 or better vision and only one patient reported some distortion [7]. Another study * Tom H. Williamson [email protected]