Shorter time to surgical repair of macula-off retinal detachment may improve final visual acuity

1. In a meta-analysis reflecting about 2,000 subjects, patients with macula-off rhegmatogenous retinal detachments (RRDs) who underwent surgical repair within 3 days of loss of central vision had significantly better final visual acuity than those who underwent repair at 4-7 days.

2. Repair of macula-on RRDs within 24 hours was associated with better final visual acuity than repair after 24 hours.

Evidence Rating Level: 2 (Good)

Study Rundown: Retinal detachment requires urgent surgical repair to preserve visual function; rhegmatogenous retinal detachment (RRD) results from a tear in the retina and is the most common type of detachment. Macula-on RRDs are typically treated with greater urgency than macula-off RRDs given decreased visual potential in macula-off RRDs. This study aimed to assess existing evidence on how the timing of RRD repair affects visual outcomes. The meta-analysis included 20 observational studies reporting best corrected visual acuity (BCVA) in nearly 2,000 patients. Macula-off RRD repair within 3 days of symptom onset was associated with significantly better final BCVA than repair in 4-7 days. This evidence was determined to be moderate quality. Differences in other outcomes — change in BCVA and likelihood of final BCVA better than 0.4 logMAR units — did not achieve significance, but did differ between macula-off repair in 0-7 days versus >7 days. Patients whose macula-on RRDs were repaired within 24 hours of presentation had significantly better final BCVA than patients who underwent repair after 24 hours. This evidence was low quality. This meta-analysis is limited by the quality and heterogeneity of the included cohort studies. For example, outcomes between macula-on and macula-off RRD cannot be compared here because studies defined the time to repair differently in each scenario. Nevertheless, this study adds to growing evidence that there are gradations in visual outcomes within the traditionally recognized 7-day window for macula-off RRD repair. For patients with both macula-on and macula-off RRDs, time means vision, and a change in paradigm for macula-off RRDs may be warranted.

Click to read the study in AJO

Relevant Reading: Rhegmatogenous retinal detachment: A review of current practice in diagnosis and management

In-Depth [meta-analysis]: Multiple surgical approaches — scleral buckling, pars plana vitrectomy, combined buckling and vitrectomy, and pneumatic retinopexy — were included. The mean post-operative follow-up time across all studies was 15.9 months. A large majority, 16 studies, examined macula-off RRDs; these studies generally defined time to repair using time from loss of central vision. The 4 studies examining macula-on RRDs used first examination as a starting time point. Final BCVA for macula-off RRD repair in 0-3 days was 0.06 logMAR units better than 4-7 days, with a 95% confidence interval (CI) of -0.09 to -0.03. Final BCVA for macula-on RRD repair in 0-24 hours was 0.02 logMAR units better than >24 hours (95% CI -0.03 – -0.01). Rates of primary reattachment did not significantly differ based on time to repair for macula-on RRD repair. Heterogeneity between studies for findings summarized here was determined to be low using the I² statistic, with the exception of final BCVA for 0-7 days versus >7 days, which had high heterogeneity.

Image: PD

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