Progressive symptomatic retinal detachment complicating degenerative retinoschisis (PSRDR) is rare, and no uniform consensus exists regarding the optimal management of PSRDR.1, 2 The surgical outcomes appear to be inferior compared with those of rhegmatogenous retinal detachment (RD).3, 4, 5 Between September and November 2012, we conducted an anonymous, online survey of PSRDR management with members of the British and Eire Association of Vitreoretinal Surgeons to obtain a contemporary snapshot of the clinical management and surgical approaches.
The survey explored five clinical scenarios: Scenario 1. How do you manage a retinoschisis with a localised, asymptomatic macula-on retinal detachment? Scenario 2. What is your surgical approach for PSRDR in the presence of a significant cataract? Scenario 3. What is your approach for a PSRDR with an anterior outer leaf break (OLB)? Scenario 4. What is your approach for a PSRDR with an OLB posterior to the equator? Scenario 5. What is your approach for a PSRDR complicated by grade B or grade C proliferative vitreoretinopathy (PVR)? Eight-four completed responses were received, including consultant vitreoretinal surgeons (77.4%), and VR fellows/specialists (14.3%). The reported annual vitrectomy surgery caseload was 101–300 in 64.3% (n=54) and 301–500 in 25% (n=21). The majority (57.1%, n=48) of surgeons undertake 6–20 scleral buckle procedures annually. The numbers of PSRDR cases managed annually were as follows: 0 cases (8%); 1 case (30%); 2 cases (30%); 3 cases (20%); 4 cases (7%); and 5 cases (5%).
In scenario 1, 15% surgeons monitor patients with serial imaging. Laser barrage treatment was undertaken by 17% of surgeons, with 10% opting for vitrectomy. The remainder of respondents would observe the patients in the outpatients clinic using slitlamp biomicroscopy without any imaging. For scenario 2, 80% would undertake combined phacoemulsification and vitrectomy surgery and 8% combined vitrectomy with lensectomy. Regarding refractive choice, 58% surgeons place a posterior chamber lens implant and 4% leave the patient aphakic. Unfortunately, 38% of surgeons did not complete their refractive choice, and the authors can only tentatively presume that a posterior chamber lens implant was placed following phacoemulsification surgery.
In scenario 3, 31% undertake cryotherapy and scleral buckle surgery, with external drainage in 5%. The remainder of surgeons elect to perform vitrectomy with retinopexy; 47% vitrectomy with gas, of which schisis deroofing/retinotomy is done in 20%; vitrectomy with oil is undertaken in 14%, combined with schisis deroofing/retinotomy in 7%; and vitrectomy with scleral buckle surgery is undertaken by 6% of surgeons. In scenario 4, all surgeons perform vitrectomy with retinopexy. In 70% surgeons, the preferred approach is vitrectomy with gas, of which schisis deroofing/retinotomy is performed by 28%. Vitrectomy with oil is the preferred choice for 26%, with combined vitrectomy with scleral buckle surgery in 3%. In scenario 5, primary vitrectomy surgery is undertaken. The majority use oil tamponade (64%) with schisis retinectomy performed by 23%; and gas tamponade by 16% with 4% employing retinectomy. The remainder of surgeons perform combined vitrectomy with scleral buckle surgery, with gas in 6%, oil in 14%, and retinectomy plus oil in 7%. Across all groups for PSRDR, the overall success rate from primary surgery was difficult to interpret. This survey is not a valid method to estimate the results/success rates of the various treatment options, as each surgeon would be dealing with very few cases and recall bias can significantly alter the true outcome estimates.
This survey highlighted the current variation in the management of PSRDR for specific clinical scenarios. The self-reported success rates for surgeons within the BEAVRS group for primary surgical intervention was not reliable, as this survey is based on individual surgeon recall of a rare surgical case(s). Grigoropoulous and co-workers3 report that PSRDR associated with anterior OLBs have better outcomes than those with posterior OLBs, and PSRDR with PVR have poorer outcomes. Optimal surgical management continues to be the subject of ongoing debate at a national level within the vitreoretinal surgical community.
The contemporary variation in clinical management and surgical approaches for this condition is highlighted by our survey. There is a lack of contemporary epidemiological data for PSRDR, and further studies are required. In the era of revalidation and benchmarking of surgical outcomes in the United Kingdom, the authors will be conducting a prospective multicentre study of PSRDR within the United Kingdom in association with the British Ophthalmic Surveillance Unit.
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The authors declare no conflict of interest.
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Muqit, M., Xue, K. & Patel, C. National survey of progressive symptomatic retinal detachment complicating retinoschisis in the United Kingdom. Eye 27, 1425–1426 (2013). https://doi.org/10.1038/eye.2013.230
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