OSLI Retina

July 2019

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408 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina Practical Retina Incorporating current trials and technology into clinical practice Developments in Fovea- Sparing RRD Repair: Reconsidering the Timing of Surgery by James C. Major Jr., MD, PhD, FACS; Seenu M. Hariprasad, MD; and Alexander M. Rusakevich, BA In this issue's Practical Retina col- umn, James C. Major Jr., MD, PhD, FACS, and Alexander M. Rusakevich, BA, from Houston discuss the timing of surgery in the management of fovea-sparing rheg- matogenous retinal detachments. We are all aware that there is great discussion and potential medico- legal ramifications regarding the tim- ing of repair for macula-on retinal detachments (RDs). Although tradi- tional thinking was that timing of re- pair should be emergent, recent data suggest otherwise. We know emergent surgeries can incur risks due to re- duced resources, fewer staff, surgeon fatigue, and lack of medical clearance for surgery and anesthesia. Recent re- search has shown that surgeries per- formed Monday through Friday were more likely to achieve single-opera- tion anatomic success than operations performed on Saturday or Sunday for various reasons. Most importantly, recent research suggests that time to RD repair does not appear to impact visual or anatomic outcomes. Given evolving data, our communi- ty needs to re-evaluate the traditional thinking that repair of macula-on RDs are emergent. I am certain that Dr. Ma- jor and Mr. Rusakevich's insights will be very valuable for updating our com- munity on the most recent data regard- ing this important topic. TRADITIONAL VERSUS RECENT APPROACHES TO FOVEA-SPARING RRD REPAIR Foveal involvement in rhegmatogenous retinal detachment (RRD) has consistently been identified as one of the most important prognostic factors correlating with postopera- tive visual outcome. 1-4 Throughout the 20th century, literature on the subject suggested a correlation between time to surgery and post- operative visual acuity (VA) and anatomic success. Traditional thinking prompted emer- gent surgery to preserve the fovea in fovea- sparing RRDs. More recently, animal models have been used to demonstrate potentially irreversible changes occurring within min- utes of retinal detachment (RD). 5-8 The timing of such pathophysiologic processes suggests that, ideally, surgical repair of RRD would be performed before foveal detachment, and it logically follows that time from presentation to surgical repair may correlate with ultimate outcomes. Interestingly, however, despite the clinical concern for fovea detachment while awaiting surgical repair, the progression of sub- retinal fluid (SRF) into the fovea appears to be rare in most recent reported case series, occurring in 0.5% (one of 199) of fovea-on eyes in one study 9 and 1.1% (10 of 930) in another study. 10 Even when SRF does eclipse the fovea, however, visual outcomes can still be preserved; Kontos et al. reported that visual outcomes were not compromised after progression of 10 cases to fovea-off status out of a total of 930 fovea-sparing RRD, although two of these eyes did lose one Snellen line. 10 Somewhat counter-intuitively, these recent retrospective stud- ies have documented little correlation of time from fovea-sparing RRD diagnosis to surgical repair with outcomes. 9-13 In a seminal series of 199 fovea-sparing RRDs managed with scleral buckle (SB), Wykoff et al. found no statistically significant difference in visual or anatomic outcomes for eyes operated within 3 days of initial evaluation. 9 Similarly in another study involving 66 macu- James C. Major Jr. Alexander M. Rusakevich doi: 10.3928/23258160-20190703-01 Seenu M. Hariprasad Practical Retina Co-Editor

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