There needs to be a fundamental rethink on the appropriate management of retinal detachments (RD), including what constitutes “successful surgery” and when is the best time to intervene, if progress is to be achieved in delivering better postoperative visual outcomes for today’s patients.
That is the provocative message which will be delivered by Heinrich Heimann MD, FRCOphth, in his Gisbert Richard Medal Lecture at the EURETINA 2021 Virtual Congress taking place from 9-12 September 2021.
“My lecture is really a call for action to reexamine a lot of the current orthodoxy surrounding RD surgery. The reality is that a patient being treated for RD by a top surgeon today will not obtain a better visual acuity outcome than if he or she had been operated by a good surgeon in the 1950s or 1960s. We wouldn’t accept this as progress in other medical fields and yet it is deemed good enough for ophthalmology,” said Dr Heimann.
Although functional and visual outcomes today are definitely better for complicated retinal detachments, the same is not true for the majority of ‘standard’ rhegmatogenous RDs, explains Dr Heimann.
“I would argue that the main driver in the evolution of techniques over the past few years has been about making life easier for the surgeon and not necessarily delivering better outcomes for the patient,” he said.
As Dr Heimann sees it, there has been too much emphasis on anatomical success rates and not enough on patients’ functional vision after RD surgery.
“Only about 60% of people can read unaided in the operated eye after retinal detachment surgery. So, about 40% of patients don’t have reading ability without visual aids in that eye, which is not very impressive. What saves us is that the other eye is usually better and doesn’t have a problem in the majority of cases. If both eyes were affected in that way, there’d be a lot more outcry about the visual acuity results which are objectively quite poor and have not improved since the 1960s,” he said.
The scientific literature also tends to mask the reality of RD success rates, points out Dr Heimann.
“If you look at the published retinal detachment studies, a lot of them only record anatomical success rates. The surgeon is really only interested in whether the retina is reattached or not, so the functional outcomes are not given the priority they should be,” he said.
Better clinical studies might also help to shed light on why the visual outcomes are often out of step with the anatomical results.
“We definitely need more research on this to understand the underlying cause, whether it is photoreceptor loss, macular pucker, chronic cystoid macular oedema, persistent fluid under the retina, or perhaps a combination of these factors. The truth is nobody really knows why some patients do well and attain 6/6 visual acuity while others only obtain 6/18,” said Dr Heimann.
Improving outcomes
Although the situation is complex, some concrete measures can be taken to potentially improve visual outcomes after RD surgery.
One critical step is to intervene as rapidly as possible irrespective of whether the patient presents with a macula-on or macula-off RD. The traditional thinking that a macula-off RD could be operated up to a week after presentation rather than be treated as emergency surgery has been challenged by recent compelling data from David Yorston and the BEAVRS group, explained Dr Heimann.
“The earlier you do the surgery the better, irrespective of whether it is macula-on or macula-off RD. That will have quite an implication on the management of these patients, but this is one of the options we have to possibly improve results here and now,” he said.
The type of surgery employed to repair the detachment may also have a bearing on outcomes. Although vitrectomy is usually the intervention of choice for RD repairs, surgeons should not rule out scleral buckling as an option.
“We conducted a trial on this some years ago and showed that while vitrectomy achieved better anatomical results in pseudophakic patients, these represent only about one third of patients. For phakic patients the anatomical outcomes were the same with either buckling or vitrectomy, but the functional results were actually better with scleral buckling,” said Dr Heimann.
Another treatment option, pneumatic retinopexy, is also making a comeback in European practices bolstered by some favourable clinical trial data from the UK and Canada.
“The trial data demonstrated that the visual acuity is better after pneumatic retinopexy compared to vitrectomy. So, both pneumatic retinopexy and scleral buckling surgery seem to deliver better functional vision compared to vitrectomy and might be considered as potential first-line treatment ahead of vitrectomy,” he concluded.
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Dr Heinrich Heimann will deliver the Gisbert Richard Lecture at 15.00 CEST on 11 September 2021. More details on registration for the EURETINA Virtual Congress 2021 here.
