Refractive surgeries are commonly performed procedures used to correct ametropias and improve patient quality of life by eliminating or decreasing the need for optical correction. A variety of procedures are available depending on the refractive error, desired outcome, and ocular status, among other factors.
Some refractive surgical procedures include:
- Laser-assisted in situ keratomileusis (LASIK)
- Photorefractive keratectomy (PRK)
- Small incision lenticule extraction (SMILE)
- Implantable contact lenses (ICL)
- Refractive lens exchange (RLE)
While many patients benefit greatly from refractive surgery, these procedures come with a variety of potential risks including that of rhegmatogenous retinal detachment (RRD).1
Rhegmatogenous retinal detachment after refractive surgery
RRD, a separation of the neurosensory retina from the retinal pigment epithelium due to an influx of fluid from the vitreous cavity through a hole or break in the retina, has been reported as a complication of refractive surgery.
Figure 1: A superior nasal retinal detachment from horseshoe tear (left) and inferior temporal retinal detachment from multiple atrophic holes in lattice degeneration (right).
Figure 1: Courtesy of Jessica Haynes, OD.
Incidence of RRD after refractive surgery
The incidence of RRD differs depending on the procedure, as shown in Table 1 below.2-5
Table 1: Incidence of RRD per refractive surgery type.2-5
| Refractive Surgery | Incidence of RRD |
|---|---|
| LASIK | 0.04 to 0.36% |
| PRK | 0.08% |
| SMILE | Not reported |
| ICL | 0.7 to 2.07% |
| RLE | 0 to 9.2% |
It is important to remember that these incidences vary significantly per the study reviewed due to factors such as the study population size, refractive error and axial lengths included, and duration of observation following surgery. For example, note that the incidence of RRD following RLE varies from 0% to as high as 9.2%.5
While RRD is established as a potential complication of refractive surgery, causation remains unclear in some instances. A majority of patients who seek refractive surgery are myopic, with many being considered high myopes (generally considered as -6.00D or greater of refractive error). This patient population inherently has an increased risk of RRD.
LASIK
In keratorefractive surgeries such as LASIK, it is unclear if the surgical procedure invokes an anatomical change to the eye that promotes RRD, or if patients undergoing surgery are generally prone to RRD and would eventually have suffered the outcome whether refractive surgery was performed or not.
Many studies examining the incidence of RRD following LASIK suggest that there is no additional risk of RRD following LASIK when compared to the natural history of RRD development in this patient population.6,7
Refractive lens exchange
In regards to RLE, it is known that cataract surgery carries a risk of retinal detachment due to increased vitreous liquefaction and forward displacement (contraction) of the vitreous body following surgery. This leads to the development of posterior vitreous detachment (PVD), potentially inducing retinal breaks that lead to RRD.
The risk of RRD in the highly myopic patient population is known to be greater than in the general population during these procedures, which must be heavily considered for RLE.5 Of note, a risk calculator has been devised by Frank Kerkhoff, MD, PhD, to predict the incidence of RRD following RLE.
The calculator takes into account age, refractive error, presence of lattice degeneration, presence of PVD, and axial length if known.
Phakic intraocular lens implants
The American Academy of Ophthalmology's Preferred Practice Pattern on posterior vitreous detachment, retinal breaks, and lattice degeneration notes that phakic intraocular lens implants “have not been associated with increased risk of retinal detachment compared with other intraocular interventions in highly myopic eyes.”8
General risk factors for RRD
Risk factors for RRD following refractive surgery include higher levels of myopia, greater axial length, and pre-existing lesions such as lattice degeneration, horseshoe tears, atrophic holes, and retinal tufts.
Figure 2: Photographs of a horseshoe tear (top left), lattice degeneration (top middle), atrophic holes (top right), retinal tuft (bottom left), a near-infrared image showing OCT location of retinal tuft (bottom middle), OCT cross-section of retinal tuft (bottom right).
Figure 2: Courtesy of Jessica Haynes, OD, FAAO.
While standard practice guidelines have been developed for the management or treatment of these peripheral retinal lesions in general,8 specific guidelines regarding prophylaxis prior to refractive surgery do not exist. Thus, practice patterns may vary depending on individual physician preferences.
It is important to remember that even those who have prophylactic treatment of peripheral retinal lesions can develop new lesions of concern, resulting in RRD following refractive surgery.5,9 Thus, even those who are previously treated must continue to be followed with careful peripheral retina examinations.
Presentation of rhegmatogenous retinal detachment
RRD can occur immediately after refractive surgery or years following the procedure. Srinivasan et al. noted that in the 5 out of 694 eyes that developed RRD following LASIK, 3 occurred within 1 year of the procedure, 1 occurred 1.5 years after, and 1 eye had an RD 7 years after LASIK.
Once again, patients who undergo refractive surgery are often high myopes who carry a lifelong risk of RRD, and the incidence of RRD will generally increase over time.5 Patients should be monitored in the short term per the protocol established by the surgeon and standard of care for a particular procedure, but should continue to be monitored at appropriate intervals lifelong with dilated examinations.
Symptoms of RRD following refractive surgery are going to be similar to RRD presentation in the general population. New onset of floaters, photopsia, and loss of peripheral vision with curtain-like shadows in the peripheral field must be taken seriously by the patient and provider. Onset of these symptoms necessitates prompt dilated fundus examination.
While many who present with RRD or at-risk peripheral lesions such as retinal tears will have an acute onset of symptoms, patients can also present asymptomatically. This once more emphasizes the need for routine dilated fundus examination regardless of symptoms.
Treatment of RRD following refractive surgery
Treatment of RRD following refractive surgery remains similar to treatment of RRD in general. Treatment options include cryopexy, laser retinopexy, pneumatic retinopexy, vitrectomy, and scleral buckling.10 Retina specialists may elect to avoid scleral buckling if possible due to changes in axial length and induced refractive error.
Unfortunately, even despite anatomical reattachment of the retina, long-term vision loss may occur due to formation of epiretinal membranes, macular atrophy, proliferative vitreoretinopathy (PVR), myopic maculopathy, and optic atrophy following RRD repair.10 Delayed patient presentation or delayed referral to a retina specialist for urgent treatment can result in worse visual outcomes.
Co-management protocol
Currently, no standard practice guidelines exist for pre-treatment of high-risk retinal lesions prior to refractive surgery, and practice patterns and preferences vary among physicians. It remains of high importance to perform a thorough dilated retinal examination to rule out pre-existing retinal lesions in patients whom you intend to refer for refractive surgery.
Patients who have aforementioned lesions, such as lattice degeneration, retinal holes, and retinal tufts, should be referred to a retinal specialist prior to refractive surgery. It is also important to give your patient an appropriate follow-up timeline with you in order to resume care and continue to monitor the patient for adverse events or new retinal findings.
Conclusions
While a causative relationship of refractive surgery to RRD remains unclear for many refractive surgeries, the fact remains that this patient population carries an increased risk for RRD than the general population.
RRD can occur immediately following surgery or years later. While refractive surgery alters the refractive status of the eye, it does not alter the posterior segment anatomy, thus predisposing high myopes to a higher lifetime risk of RRD.
Prior to surgery, the potential risk of RRD and need for continued care even once refractive error is corrected should be discussed with patients. In addition, a thorough dilated fundus examination should be performed prior to surgery to identify risky peripheral retinal lesions, with consideration of prophylactic treatment. In the long-term, patients should continue to be monitored routinely.
