Retinal detachment repairs have been done surgically since the early 1800s when English eye surgeon James Ware made the first operation in 1805 using a knife to puncture the sclera in order to drain subretinal fluid.¹ Surgeons have since come at retinal detachments in a variety of ways, dependent upon the patient’s history and the particular type of detachment. 

Here, experts detail how they select the best procedure for the job, as well as what’s on the horizon for retinal detachment repair and treatment.

Planning Your Approach

In addition to dealing with the very common rhegmatogenous retinal detachment, surgeons say there are a few other considerations to keep in mind when approaching a detachment patient.

If someone has a tractional detachment due to diabetes, this can cause some issues in the operating room. “In terms of repairing retinal detachments, the most difficult ones are probably diabetic retinal detachments because there’s an underlying disease process,” says Tien Wong, MD, a retina specialist at Retina Consultants of Texas in Houston. “Usually, there’s a lot of scar tissue and those are probably the more challenging cases.” 

Exudative retinal detachments also bear some extra consideration when planning treatment. “Exudative types of retinal detachments can be caused by a variety of things,” notes Patrick Staropoli, MD, also a retina specialist at RCTX. “Sometimes it has to do with inflammation inside of the eye, either an infection or an inflammatory process. It can be caused if someone has a cancerous process in their eye that can also cause fluid to build up underneath the retina. In these cases, you’re mostly targeting the cause of that fluid buildup. That calls for more of a medical treatment.”

Surgical Pearls

For surgical repair of detachments, there are various options, and surgeons say some of them can go hand-in-hand. For the most common case of retinal detachment, rhegmatogenous, (according to the IRIS Registry, 237,646 patients underwent rhegmatogenous retinal repair in 2020 alone),² surgeons say there are certain initial steps you can take to help increase the chance of a good outcome.

“One of the things I assess first for a primary retinal detachment is the status of the vitreous,” says Dr. Wong. “Do they have a vitreous separation? Because that changes how you would treat the patient. If it’s a long-standing retinal detachment from somebody who was born with holes in the retina and they’re young and their vitreous isn’t separated from the retina, then vitrectomy isn’t always the first choice for surgery.”

Proliferative vitreoretinopathy is the major cause of failure after retinal detachment surgery and the success rate of PVR surgery is unsatisfactory. Currently, there are multiple adjuncts being tested for the treatment and prevention of PVR, including methotrexate.

Dr. Staropoli details how he approaches patients with rhegmatogenous detachments. “I think the main thing we want to ascertain with the patient is their history,” he explains. “When did their symptoms start? Is this a process that’s been going on for a long period of time or is it sudden? You want to get a sense for a couple things that will determine how you fix them surgically. So, patient’s age is important, as well as their lens status and if they’ve had cataract surgery before or they’re still phakic. 

“The vitreous in a young patient is very thick, sticky, and adherent to the retina,” says Dr. Staropoli. “As you get a little bit older and you have that posterior vitreous detachment or the vitreous starts to liquify, this makes doing a vitrectomy surgery a little easier. So, you want to talk to the patient, get their history, examine their eye for all those key things and then that sort of helps you decide what surgical approach you’re going to take.”

Once you understand the patient’s history, you can better determine which surgical technique might be best. “People still have their own expertise or opinion about what works better in certain situations,” Dr. Staropoli says. “I have general guidelines that I follow. Obviously, every case can have its nuances that you may take to do something different, but if I have a young patient with a retinal detachment, I would always try to do a scleral buckle first. 

“You would also do cryotherapy on the tear,” Dr. Staropoli continues. “You’re basically trying to repair the retina from an outside approach without having to go inside the eye. This works nicely because in young people you don’t want to-if you don’t have to-try to remove the vitreous because that can lead to additional tears. Young patients can sometimes heal with a lot of inflammation and scarring, and that can cause re-detachments. So, in general, I’d say most people would prefer to start with a scleral buckle approach for a young patient. If that doesn’t work, then the next surgical step would be moving on to a vitrectomy.

Dr. Staropoli outlines the different methods to performing a buckle. “Though buckling is done pretty much the same as it’s always been,” he says, “there are two camps in terms of how you put the scleral buckle on the eye. Some people like to suture it. However, when I trained at Bascom Palmer, we made scleral belt loops, which involved creating a partial-thickness scleral incision. You use a 64 blade and a Castroviejo scleral dissector, and you make the loops. Then, you pass the buckle through those loops rather than suturing it.”

Dr. Staropoli details his approach for the older RD patient. “Now, when the patient age gets a little bit older, then we’re talking about the most common patient: someone in their 50s who still has their native lens (maybe it’s a cataract at this point),” he says. “When they come in with a retinal detachment, in those cases I prefer to do a scleral buckle and a vitrectomy. You treat the tears at that time with a laser to ‘tack down’ the retina in that area right next to the tears, and those patients generally do very well.” 

For pseudophakic patients, the approach changes still. “The last category would be an older patient who’s already had cataract surgery, so they’re pseudophakic,” Dr. Staropoli says. “Their vitreous gel at this point is more liquified. They probably already have a posterior vitreous detachment. Those are patients I’d consider just doing a vitrectomy on and then using a gas bubble, because their vitreous poses a little bit less of a problem and you can fix the retina just as well with a vitrectomy.”

Tractional retinal detachments require a similar approach. “For diabetic retinal detachments, it’s almost always vitrectomy,” says Dr. Wong. “Also, the results for diabetic retinal detachments have improved with the use of anti-VEGF medications pre-operatively to reduce retinal neovascularization, which reduces intraoperative bleeding.”³ Surgeons have found that anti-VEGFs like bevacizumab, ranibizumab, aflibercept and others can help reduce intraoperative hemorrhage in the presence of large, active neovascular fronds, which may make repairing the detachment easier. Additionally, panretinal photocoagulation can assist with surgery. Some surgeons have found that this helps stabilize the eye in case of proliferative diabetic retinopathy in tractional retinal detachment cases.

Pneumatic Retinopexy’s Place

Surgeons say that pneumatic retinopexy can still be useful in particular cases.

“Pneumatic retinopexies are great in certain situations,” says Dr. Staropoli. “So, if a patient is too sick to medically undergo anesthesia or have a surgery in the operating room, or if you’re a doctor who’s practicing in an area where you don’t have great access to an operating room, then pneumatic retinopexy could be an option.”

However, PR isn’t perfect. “The success rate isn’t as high as either scleral buckling, vitrectomy or a combination of both,” says Dr. Wong. 

In a systematic review of articles comparing pneumatic retinopexy and vitrectomy, researchers divided patients into two groups: treatment-naïve and previously treated patients.⁴ For patients who received a vitrectomy for retinal detachment repair (n=4,360), 91 percent of treatment-naïve patients’ visual acuity improved, and 85 percent of previously treated patients’ visual acuity improved. For patients who received a pneumatic retinopexy for retinal detachment repair (n=1,577), 69 percent of treatment-naïve patients’ visual acuity improved, and 33 percent of previously treated patients’ visual acuity improved.

“So, when you do pneumatic retinopexy, it’s usually done for people who are very limited in terms of the number of tears,” explains Dr. Wong. “You often do them in people who have acute retinal detachments due to a peripheral vascular disease and a retinal tear that are located superiorly. However, if the tear is inferiorly located, pneumatic retinopexy wouldn’t work.” Concurrent cryotherapy is used to seal the tears.

“The whole goal is that you avoid having to take the patient into surgery,” comments Dr. Staropoli. “In the right patient, it works very well, and if you’re not able to get them into the operating room, then it’s a really good option.”

Surgeons detail how they employ laser or cryo-therapy during RD repair. “When we do scleral buckling, we primarily do cryo-retinopexy,” explains Dr. Wong. “But, when we do vitrectomy, we usually flatten the retina, reattach it and then add laser retinopexy. Therefore, in somebody you put a scleral buckle on when you’re initially treating them, the retina becomes elevated. When it’s elevated, the laser won’t take, so then you have to use cryo-retinopexy.”

Other Detachments

There are some cases, especially exudative retinal detachment cases, that require different methods of treatment. “You could see serous retinal detachments in someone with central serous retinopathy, which is associated with steroid use,” says Dr. Staropoli. “This can be treated medically just by taking the patient off of whatever systemic steroid medications they’re on. 

“In neoplastic causes, people presenting with choroidal melanoma or metastasis from a cancer or somewhere else in the body-you’d see a serous retinal detachment. Obviously, the main treatment would be systemic,” continues Dr. Staropoli. “If they have metastatic cancer or if they have a choroidal melanoma, we sometimes treat them with plaque radiotherapy.”⁵ 

Improvements to Repair Techniques

“I think that the field is constantly evolving in terms of the instruments and machines we use,” says Dr. Staropoli. “There are several different vitrectomy machines on the market now and what machine you use is usually dictated by whatever your hospital or practice has, but the instrumentation that we use continues to get smaller and smaller. So, way back when, before my time, they used to use large 20-gauge instruments to repair retinal detachments. Twenty-three-gauge then became more common. I’d say for me, in my training and at my practice, I more commonly use 25-gauge instruments, but they make 27-gauge, as well. So, vitrectomy is becoming less invasive. There’s sort of a trade-off in terms of how easily you’re able to maneuver the instruments and how quickly they’re able to remove the vitreous gel, however. The smaller you get, the more difficult that is. I’d say a lot of people today use 25-gauge.”

Dr. Wong says the improved instrumentation has improved results. “When I first started practice over 30 years ago, the success rate for primary detachments was about 80 percent or so,” he says. “Now, I think it’s much closer to 90 to 95 percent with a single operation. The technology has improved dramatically. When I started, the equipment we used for vitrectomy, for example, would cut at a very slow rate, about 400 cycles per minute. Whereas now they’re at 20,000. So, illumination and vitrectomy technology have improved over the past 30 years, and our techniques have evolved, as well.”

Besides advancements to decrease the invasiveness of surgery and procedural time, there are ongoing trials and treatments that can better assist with managing proliferative vitreoretinopathy, which is a key reason for failure of RD repair.

 “About 5 to 10 percent of patients⁶-sometimes it can be more depending on the case-are at risk for developing scarring after repair of a retinal detachment,” says Dr. Staropoli. “That’s the leading cause for the retina re-detaching or requiring another surgery.

“People have looked at therapeutic options for this for a very long period of time,” Dr. Staropoli continues. “Steroids have been used in every formulation. There’s been other agents like heparin, anti-VEGF agents, 5-fluorouracil—they’ve all been tried but nothing has definitively helped us with this problem. The newest agent that people are using now is methotrexate. There was a large study of methotrexate’s use called the GUARD trial [Gain Understanding Against Retinal Detachment], that was completed a year or two ago, but the final paper and results haven’t come out yet. GUARD was showing really good promise for preventing PVR from developing and keeping these high-risk retinas attached. It’s interesting because the researchers followed a pretty intensive protocol. These patients had to get an injection of methotrexate in the eye every week after the surgery for several weeks, and then every two weeks after that. So, it’s pretty labor intensive, but it could have a significant benefit in terms of preventing re-detachment.”

The GUARD trial was conducted for the FDA approval of ADX-2191 (intravitreal methotrexate 0.8%) from Aldeyra. According to Aldeyra, this drug was injected 13 times over 16 weeks after patients completed vitrectomy surgery for a retinal detachment. Here are the top-line results from Part 1 of the Phase III GUARD trial:⁷

• After a six-month period, 16 patients who received ADX-2191 (n=68) experienced a retinal detachment while 113 patients who received a standard procedure (n=292) experienced a retinal detachment;

• Letters of visual acuity achieved in ADX-2191 patients was 32.9 while 36.5 was achieved in the standard procedure candidates;

• Central macular subfield thickness in ADX-2191 patients was 382 µm while patients who received a standard procedure achieved 484 µm;

• Punctate keratitis was the most common adverse event in patients who were administered ADX-2191 (n=11, 16 percent). Nine cases were considered mild, while two cases were considered moderate;

• Treatment was discontinued in one patient due to scheduling conflicts.

Retinal detachments are a familiar territory for any retina specialist, and the landscape of technology and pharmaceuticals continues to advance, helping to improve success rates in surgery. However, another struggle lies with patients’ awareness of detachment symptoms. “I think the main thing, especially when I meet a lot of patients, is that they’re not sure when is the right time to come in and get their eyes checked, and they don’t know if the symptoms they’re experiencing are actually something that would require urgent surgical repair,” says Dr. Staropoli. “Perhaps raising more awareness for those classic symptoms-the flashes and floaters-can encourage people to get their eyes dilated and checked by an ophthalmologist or a retina specialist because it could be something serious. 

“People are sometimes really good at compensating when, for example, their non-dominant eye has a retinal detachment and therefore they don’t recognize the symptoms,” Dr. Staropoli continues. “Something as easy as covering up one eye, then the other eye and then noticing some flashes and floaters will help people figure out which eye it’s coming from and encourage them to get in to see their eye doctor. The earlier you identify these problems, the easier they are to fix and the better visual and anatomical outcomes we can have.”

Drs. Staropoli and Wong have no financial interests to disclose.

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^{2. Saraf SS, Lacy M, Hunt MS, et al. Demographics and seasonality of retinal detachment, retinal breaks, and posterior vitreous detachment from the intelligent research in sight registry. Ophthalmology Science 2022;2:2:100145.}

^{3. Mishra C, Tripathy K. Retinal Tractional Detachment. StatPearls. Treasure Island (FL): StatPearls Publishing 2024.}

^{4. Roshanshad A, Shirzadi S, Binder S, et al. Pneumatic retinopexy versus pars plana vitrectomy for the management of retinal detachment: A systematic review and meta-analysis. Ophthalmol Ther 2023;12:2:705-719.}

^{5. The Collaborative Ocular Melanoma Study Group. The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, III: Initial mortality findings: COMS Report No. 18. Arch Ophthalmol 2001;119:7:969–982.}

^{6. Pennock S, Haddock LJ, Mukai S, et al. Vascular endothelial growth factor acts primarily via platelet-derived growth factor receptor α to promote proliferative vitreoretinopathy. Am J Pathol 2014;184:11:3052-68.} 

^{7. Top-line results from part 1 of the phase 3 GUARD trial of ADX-2191 in proliferative vitreoretinopathy. Aldeyra Theraputics 2022. https://ir.aldeyra.com/static-files/cde1aa20-d22a-4f38-a9a5-523b803aca40.}