National survey of progressive symptomatic retinal detachment complicating retinoschisis in the United Kingdom

Outcomes of surgical repair of Retinoschisis-associated retinal detachment compared to Rhegmatogenous retinal detachment

Background

The aim of this study is to compare outcomes of primary retinal detachment (RD) repair in retinoschisis-associated RD (RSRD) and rhegmatogenous RD (RRD).

Methods

This is a retrospective observational cohort study. Charts of 2247 consecutive patients operated for RD repair at the Centre hospitalier universitaire de Québec – Université Laval between 2014 and 2018 were reviewed. Patients with RSRD and RRD were included to compare the visual and anatomical outcomes of both groups.

Results

There were 41 patients (1.8%) with RSRD and 1661 patients (74%) with RRD. RSRD patients had more primary repair failures (n = 9, 22%, vs. n = 166, 10%; p = 0.013). The primary anatomical success rates for pars plana vitrectomy with and without scleral buckle (PPV-SB vs. PPV) as primary repair method were similar in both RSRD patients (n = 11/14, 79% vs. n = 20/25, 80%; p = 0.92) and RRD patients (n = 751/827, 91% vs. n = 641/721, 89%; p = 0.21). At final follow-up, best corrected visual acuity (VA) in logarithm of the minimum angle of resolution (logMAR) was 0.30 [0.10, 0.88] and 0.18 [0.10, 0.40] (p = 0.03) in RSRD patients and RRD patients, respectively. Presence of retinoschisis was associated with worse final VA (β 0.082, p < 0.001). Other predictive variables included female sex, macula-off presentation, number of RD quadrants involved, longer symptoms duration, worse baseline VA, and primary repair failure. The greatest predictors were worse baseline VA, primary repair failure, and macula-off status at presentation. Presence of retinoschisis did not significantly increase risk of primary repair failure in multivariable analysis (OR 1.45, 95% CI: 0.50–4.17; p = 0.49). Symptoms duration was the greatest effect factor associated with for primary repair failure (OR 1.37, 95% CI: 1.12–1.69; p = 0.003).

Conclusions

RSRD is associated with more primary repair failure in univariate analysis, but not in multivariate analysis after adjusting for symptoms duration. It is however associated with worse final VA even after adjusting for primary repair failure. Both PPV and PPV-SB are valid repair methods for RSRD. However, RSRD remains a challenge to treat.

Diagnosis and Management of Degenerative Retinoschisis and Related Complications

Degenerative retinoschisis is a common condition characterized by elevation of the inner layers of the peripheral retina. While uncomplicated retinoschisis (i.e. with no associated retinal layer breaks) is almost invariably a benign process, retinal detachment associated with isolated outer layer breaks (termed schisis-detachment) is fairly common. Historically, schisis-detachment has been treated with a variety of interventions ranging from retinopexy to intraocular surgery. Based on published descriptions of the natural history of the disease, these interventions are likely unnecessary in many cases and may place the patient's vision at unnecessary risk. Progressive symptomatic schisis-related retinal detachment, on the other hand, is a vision threatening condition that requires intervention. While clinical examination remains the mainstay of diagnosis, recent advances in multimodal imaging can provide supplemental information in subtle cases and may prove valuable for long-term disease monitoring. When evaluating patients with peripheral retinal elevation, it is important for ophthalmologists to make an accurate diagnosis and understand the risk-benefit ratio associated with intervention. Thus, we summarize the current literature on the natural history, clinical and imaging diagnosis, and surgical management of degenerative retinoschisis and its related complications.

Repair of progressive retinal detachment complicating degenerative retinoschisis: surgical management and outcomes in phakic eyes

BACKGROUND

Degenerative retinoschisis is a common condition defined by the splitting of the neurosensory retina that may rarely be associated with progressive retinal detachment (RD). Here, we aim to describe the anatomic and functional outcomes of surgical treatment of progressive symptomatic retinal detachment complicating degenerative retinoschisis (PSRDCR) using pars plana vitrectomy (PPV), scleral buckle (SB), or combined PPV/SB procedure.

METHODS

A retrospective chart review of patients with PSRDCR between Jan 1, 2008 and Dec 31, 2019 was conducted. Data regarding demographics, surgical approach, and anatomic/functional outcomes were collected.

RESULTS

Of the 4973 charts with RD repair during the study period, 36 eyes (0.7%) had retinoschisis with RD. 18 eyes met inclusion criteria (0.4%). The median age was 54 years (range 18-74) and all eyes were phakic. All eyes had outer layer breaks (OLBs) and 16 eyes (89%) had identifiable inner layer breaks. All OLBs were posterior to the equator in charts where position was recorded (16 eyes). The single surgery anatomic success (SSAS) and final anatomical success rates were 66% (12/18) and 100%, respectively. Eyes treated with PPV/SB had an SSAS rate of 75% (9/12), while PPV and SB had SSAS rates of 66% (2/3) and 33% (1/3), respectively.

CONCLUSIONS

PSRDCR is an exceedingly rare complication of degenerative retinoschisis associated with an SSAS rate lower than for uncomplicated rhegmatogenous RD. The majority of PSRDCR were repaired via combined PPV/SB in our study, and the rarity of this complication limits statistical support of an optimal surgical method in our and prior studies. The role of SB combined with PPV for PSRDCR requires further investigation.

Incidence, mechanism and outcomes of schisis retinal detachments revealed through a prospective population-based study

AIM

To determine the incidence, presentation and outcomes of progressive sight-threatening retinal detachment (RD) complicating degenerative retinoschisis.

METHODS

We conducted the first prospective population-based epidemiological study of progressive schisis detachment over a 1-year period (2014-2015) in the UK. Case ascertainment was via monthly British Ophthalmological Surveillance Unit reporting cards sent to all ophthalmologists in the UK. For each reported case, data were collected using incident and 6 months follow-up questionnaires gathering information including demographic, presenting symptoms, retinal findings, primary management, primary outcome, secondary management and secondary outcome.

RESULTS

Fifty-five cases of progressive schisis RD were identified with similar age distribution to conventional rhegmatogenous RD (mean age 64.0 years, range 20-88), and male-to-female ratio of 2.3:1. The locations of schisis detachments were predominantly supratemporal (46.7%) and infratemporal (35.6%). At least 70% of schisis RD were associated with posterior vitreous detachment (PVD) at presentation and 21% with grade B-C proliferative vitreoretinopathy. Primary management consisted of pars plana vitrectomy (82%), scleral buckle (9%), observation (4%), laser (2%) and combined vitrectomy-buckle (2%). Primary reattachment rate was 70%. Final reattachment rate was 87% with mean best-corrected visual acuity of 0.49 Decimal (SD 0.34) for fovea-on and 0.42 Decimal (SD 0.29) for fovea-off schisis detachments at mean follow-up of 8.7 months (SE 1.0).

CONCLUSIONS

The estimated annual incidence of progressive schisis RD was 0.85 per million population (95% CI 0.64 to 1.11), equivalent to around 0.66% of all rhegmatogenous RD. PVD may play a key pathogenic role in the development of progressive schisis detachments. Surgical outcomes are inferior to those of conventional rhegmatogenous RD.

Retinoschisis transposition following a retinal detachment repair

Objective: The authors have observed this phenomenon of translocation of the schisis cavity in a few previous cases and aim to report this unusual finding.

Method: A patient with known superotemporal retinoschisis developed a distinctly separate inferotemporal retinal detachment in his left eye. This was repaired with a vitrectomy, cryotherapy and C2F6 tamponade under local anaesthetic. Following surgery, the retinoschisis was found in the inferonasal quadrant of the eye and remained stable as the gas dispersed.

Result: We hypothesise that the tamponading agent compressed the viscous fluid within the area of schisis, displacing the area of schisis circumferentially.

Conclusion: This case emphasises that as long as the retinal breaks are properly sealed, no intervention is required with the schisis during rhegmatogenous retinal detachment surgery.