Sir,
Four letters in the correspondence section of The Journal prompt me to join the debate about the setting in which retinal detachment surgery is undertaken, both with respect to urgency and surgical facility.1, 2, 3, 4 This is an ongoing debate and has been discussed in This Journal before.5
The first fallacy that needs to be highlighted is about the urgency of management of macula-on detachments. Although it is taken for granted that all macula-on detachments should be operated on within hours of presentation, if not minutes, there is no scientific evidence to support this. The body of published evidence about the timing of surgery roughly divides into two groups. One set of reports indicate that the timing of surgery should be within 1 month of macular detachment.6, 7, 8, 9 The other group of reports indicates that there is no benefit in urgent surgery as long as scheduled surgery can be performed within 7–10 days.10, 11, 12, 13 Thus, best evidence-based practice would dictate that surgery for ‘macula-on’ detachments should be a scheduled event within 7 days of occurrence. This evidence shows that there is no need for out-of-hours surgery, be it over the weekend, as the outcome has not been scientifically shown to be better. In fact, there is an argument to support the contention that out-of-hours surgery may have worse results for various reasons, including the absence of an appropriate team, limited facilities, and possibly a senior trainee operating unsupervised. Perhaps it is time to heed the ‘my mother’ test. I recently saw a colleague's mother with a macula on retinal detachment on a Friday afternoon with a 5-day history of acute onset floaters. I offered to operate on her the same night, at which she responded ‘what have you been doing all day!’ I honestly responded that I had been operating all morning and then had a busy clinic in the afternoon, at which she suggested that I could not be expected to operate at my best that night and she would rather have her surgery on Monday morning.
The second fallacy in this debate is the perceived divide between tertiary centres and district general hospitals. Clearly, the divide should be between surgeons with adequate experience and those without, irrespective of the setting in which they practice. Therefore, a consultant in a district general hospital with the skills and facilities would entirely appropriately operate on retinal detachments but the unsupervised senior trainee (fellow/ASTO) would not, even in a tertiary referral centre.
There needs to be a radical rethinking on the appropriate management of retinal detachments, especially the ‘urgent’ ones, and this debate needs to be informed by evidence not opinion.
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Prasad, S. The urgency and site of retinal detachment surgery. Eye 20, 1105–1106 (2006). https://doi.org/10.1038/sj.eye.6702144
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DOI: https://doi.org/10.1038/sj.eye.6702144
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