Can you get Bilateral Rhegmatogenous Retinal Detachment following phacoemulsification cataract surgery?

Ahmed Ellabban

Rhegmatogenous retinal detachment (RRD) involves the separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE) due to a tear or break in the retina. This allows fluid to pass from the vitreous space into the subretinal space (1). RRD is a well-known sight-threatening complication of cataract surgery, which represents the most performed elective surgical procedure in the developed countries (2). 

Despite treatment advances, functional results remain poor, with only 42% achieving 20/40 vision and only 28% of the macula is involved, depending on the duration of macular detachment (3). Stein et al included RRD alongside with endophthalmitis and suprachoroidal haemorrhage as severe adverse events that can follow cataract surgery (4). Despite the progressive decline in rates of these severe complications over time, as described by those authors and reflected in the steady reduction in 5-year cumulative incidence from 0.96% in the early 1990s to 0.25% in the early 2000s reported in the large population-based study by Clark et al., the absolute number of patients affected by RRD continues to rise (3 – 5).

A likely explanation for this resides in the higher life expectancy and advances in cataract surgery that has resulted in a vast increase to the number of pseudophakic individuals in developed countries over the past decades. In the UK alone, the rate of cataract surgery rose 3.7-fold between 1989 and 2004 (6). Based on U.S. Census projections and multiple population-based studies, the 2004 Eye Diseases Prevalence Research Group reported that an estimated 6.1 million Americans aged >40 years had pseudophakia or aphakia (5.1% prevalence), and projected that number would increase to approximately 9.5 million by 2020 as a consequence of population ageing and increases in cataract surgery rates (7).

Available population-based and cataract-surgery cohort data demonstrate that the risk of rhegmatogenous retinal detachment is significantly increased following cataract extraction compared with the unoperated population. Large registry and cohort studies have reported cumulative pseudophakic RRD incidences ranging from approximately 0.2% to over 3% depending on duration of follow-up and patient risk profile, including axial myopia and age at surgery (4, 5). In contrast, general population studies from New Zealand, Scotland and China have reported annual RRD incidences of approximately 8–18 per 100,000 population, varying by age and region (8 – 10), indicating a substantially lower baseline risk in phakic individuals. Together, these data support a strong association between cataract surgery and subsequent RRD. Pseudophakic RRD may occur at variable time points following surgery, with cases reported both in the early postoperative period and many years later, reflecting the long-term alteration of vitreoretinal traction following lens extraction (4, 5).

Risk factors for pseudophakic retinal detachment include anterior vitrectomy for vitreous loss complication at the time of cataract surgery, male sex, young patient age, high axial myopia, Marfan’s syndrome, and previous retinal detachment repair (5, 11 – 15).

Condition review of RRD following uncomplicated phacoemulsification cataract surgery

To the best of our knowledge, bilateral rhegmatogenous retinal detachment following uncomplicated phacoemulsification has not previously been reported. We reflect on the need for this condition review having been inspired by a case in which bilateral RRD followed what had appeared to be straightforward cataract surgery.

Here, a highly myopic male was referred due to progressive glare and reduced visual function. Mixed nuclear and cortical cataracts were found on examination, and a sequential bilateral phacoemulsification was performed. Early postoperative recovery was good. Several months later, the patient presented with visual distortion and photopsia in one eye and was found to have a rhegmatogenous retinal detachment with early macular involvement. This was managed successfully with pars plana vitrectomy, retinopexy and gas tamponade. Shortly afterwards, the fellow eye developed a macula-off detachment, which was treated with a similar surgical approach. At follow-up, both retinas remained attached, although visual recovery was asymmetric.

This experience highlights how bilateral retinal detachment may occur over a short interval after cataract surgery in susceptible eyes, even in the absence of obvious pre-operative retinal pathology, underscoring the importance of careful counselling and prompt review of new symptoms.

Discussion and learning points

Functional results of the surgical treatment of RRD remain non satisfactory in a considerable number of patients. Fortunately, RRD is a not common condition, with an overall annual incidence of 8:100000, that increases to 22:100000 for individuals aged 60 or more (10). It can be idiopathic, though more often occurs secondary to trauma, tractive hole formation, heredodegenerative disorder and intraocular surgery. Benson et al found that aphakic eyes following intracapsular cataract surgery had a 4-fold increased risk of retinal detachment in comparison to phakic non-operated eyes (18). Norregaard et al reported a rate of pseudophakic RRD of 1.2 per 1000 cataract surgery in eyes with no other risk factors (17). These include previous RRD or retinal detachment in the fellow eye, predisposing retinal lesions even if treated, vitreous loss during surgery, young age and Caucasian ethnicity (5, 11, 16).  

In this context, the case we herein report is unusual: besides the fact that the patient was highly myopic, he did not have any of the other reported risk factors for pseudophakic retinal detachment and was operated on by the same high volume cataract surgeon, who employs a standardized surgical technique and postoperative treatment. Interestingly, no evidence of myopic peripheral retina lesions was found, nor a posterior vitreous detachment was described prior to cataract surgery in neither of the eyes. In fact, the increased risk of RRD following cataract surgery in young patients might be due to the stronger adherence of the vitreous cortex to the retina (19).

These considerations are particularly important in patients undergoing clear crystalline lens surgery as a refractive procedure at any age to evaluate the risk:benefit ratio. Surprisingly, several small case-series reported a zero-incidence of RRD following uncomplicated lens extraction in highly myopic eyes (20-23). Conversely, Barraquer et al reported a rate of 7.3% of pseudophakic RRD after clear lens extraction (24).

An additional point of interest is the time interval between cataract surgery and the onset of retinal detachment, which in this experience appeared broadly similar between the two eyes. This observation highlights how, in some patients, retinal detachment may develop over comparable postoperative time frames following sequential procedures, raising considerations about the temporal pattern of risk after cataract surgery. Regarding timing of retinal detachment after cataract surgery, a population-based longitudinal study showed that 41% and 71% of the eyes developed pseudophakic retinal detachment within 2 and 5 years from cataract surgery, respectively (25). It also showed how the cumulative incidence steadily rise over time, from 0.27% at 1 year to 1.79% at 20 years after cataract surgery. On the other side, a quarter of the RRDs after clear lens extraction were reported within the first 6 months from the first intraocular surgery, which might point towards a shorter time interval in myopic patients (23).

Reflecting on this experience, it has prompted us to reconsider our assessment of myopic patients, particularly those under the age of 60 who do not demonstrate a complete posterior vitreous detachment on fundoscopy. In such cases, we now recognise the potential value of macular OCT to help identify incomplete PVD and to better inform pre-operative counselling about vitreoretinal risk.

This encounter also led us to reflect on the implications for immediate sequential bilateral cataract surgery, given that retinal detachment in the fellow eye poses a significant threat to vision. While bilateral rhegmatogenous retinal detachment following immediate sequential bilateral cataract surgery has not been reported in the literature, our experience highlights how bilateral visual compromise could plausibly occur if detachments develop within a similar postoperative time frame in both eyes. Although the simultaneous onset of bilateral RRD after uncomplicated phacoemulsification is rare, this case illustrates that sequential bilateral involvement over a short interval is possible and raises important considerations when counselling patients undergoing bilateral procedures.

Conclusion

This condition review presents an unusual occurrence of non-simultaneous bilateral rhegmatogenous retinal detachment following uncomplicated phacoemulsification cataract surgery in a patient without known risk factors, except for high myopia. Despite the rarity of this complication, it highlights the importance of thorough preoperative evaluation, particularly in myopic individuals without complete posterior vitreous detachment.

We propose performing macular OCT in such cases to assess the vitreous state and counsel patients accordingly regarding the potential risk of RRD. Additionally, this case underscores the need for careful consideration when performing immediate sequential bilateral cataract surgery, as bilateral visual impairment due to RRD is a possibility, even if the likelihood of simultaneous bilateral RRD is low.

Prompt recognition and timely surgical intervention are crucial in managing rhegmatogenous retinal detachments to optimize functional outcomes. Continued vigilance, preoperative risk stratification, and appropriate patient education remain essential in minimizing the risk of this sight-threatening complication after cataract surgery.

References

  1. Sultan, Z.N., Agorogiannis, E.I., Iannetta, D., Steel, D. and Sandinha, T., 2020. Rhegmatogenous retinal detachment: a review of current practice in diagnosis and management. BMJ open ophthalmology, 5(1), p.e000474
  2. Day, A.C., Donachie, P.H.J., Sparrow, J.M. and Johnston, R.L., 2015. The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications. Eye, 29(4), pp.552-560
  3. Pastor JC, Fernández I, Rodríguez de la Rúa E, Coco R, Sanabria-Ruiz Colmenares MR, Sánchez-Chicharro D, Martinho R, Ruiz Moreno JM, García Arumi J, Suárez de Figueroa M, Giraldo A, Manzanas L. Surgical outcomes for primary rhegmatogenous retinal detachments in phakic and pseudophakic patients: the Retina 1 Project–report 2. Br J Ophthalmol 2008 Mar;92(3):378-82.
  4. Stein JD, Grossman DS, Mundy KM, Sugar A, Sloan FA. Severe adverse events after cataract surgery among medicare beneficiaries. Ophthalmology 2011 Sep;118(9):1716-23
  5. Clark A, Morlet N, Ng JQ, Preen DB, Semmens JB. Risk for retinal detachment after phacoemulsification: a whole-population study of cataract surgery outcomes. Arch Ophthalmol 2012 Jul 1;130(7):882-8.
  6. Keenan T, Rosen P, Yeates D, Goldacre M. Time trends and geographical variation in cataract surgery rates in England: study of surgical workload. Br J Ophthalmol 2007 Jul;91(7):901-4.
  7. Congdon N, Vingerling JR, Klein BE, West S, Friedman DS, Kempen J, O’Colmain B, Wu SY, Taylor HR; Eye Diseases Prevalence Research Group. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol 2004 Apr;122(4):487-94.
  8. Polkinghorne, P.J. and Craig, J.P., 2004. Northern New Zealand rhegmatogenous retinal detachment study: epidemiology and risk factors. Clinical & experimental ophthalmology, 32(2), pp.159-163
  9. Mitry, D., Chalmers, J., Anderson, K., Williams, L., Fleck, B.W., Wright, A. and Campbell, H., 2011. Temporal trends in retinal detachment incidence in Scotland between 1987 and 2006. British journal of ophthalmology, 95(3), pp.365-369
  10. Li, X., Beijing Rhegmatogenous Retinal Detachment Study Group, 2003. Incidence and epidemiological characteristics of rhegmatogenous retinal detachment in Beijing, China. Ophthalmology, 110, pp.2413-2417
  11. Erie JC, Baratz KH, Hodge DO, Schleck CD, Burke JP. Incidence of cataract surgery from 1980 through 2004: 25-year population-based study. J Cataract Refract Surg 2007; 33:1273–1277
  12. Alldredge, C.D., Elkins, B. and Alldredge Jr, C.O., 1998. Retinal detachment following phacoemulsification in highly myopic cataract patients. Journal of Cataract & Refractive Surgery, 24(6), pp.777-780
  13. Fan, D.S., Lam, D.S. and Li, K.K., 1999. Retinal complications after cataract extraction in patients with high myopia. Ophthalmology, 106(4), pp.688-692
  14. Abboud, E.B., 1998. Retinal detachment surgery in Marfan’s syndrome. Retina, 18(5), pp.405-409
  15. Tielsch, J.M., Legro, M.W., Cassard, S.D., Schein, O.D., Javitt, J.C., Singer, A.E., Bass, E.B. and Steinberg, E.P., 1996. Risk factors for retinal detachment after cataract surgery: a population-based case-control study. Ophthalmology, 103(10), pp.1537-1545
  16. Mitry D, Charteris DG, Fleck BW, Campbell H, Singh J. The epidemiology of rhegmatogenous retinal detachment: geographical variation and clinical associations. Br J Ophthalmol 2010 Jun;94(6):678-84.
  17. Norregaard JC, Thoning H, Andersen TF, et al. Risk of retinal detachment following cataract extraction: results from the International Cataract Surgery Outcomes Study. Br J Ophthalmol 1996; 80:689–693
  18. Benson WE, Grand MG, Okun E. Aphakic retinal detachment. Management of the fellow eye. Arch Ophthalmol. 1975 Apr;93(4):245–249. doi:10.1001/archopht.1975.01010020255001.
  19. Erie JC, Raecker MA, Baratz KH, Schleck CD, Burke JP, Robertson DM. Risk of retinal detachment after cataract extraction, 1980–2004: a population-based study. Ophthalmology. 2006 Nov;113(11):2026-2032. doi:10.1016/j.ophtha.2006.05.054.
  20. Gris, O., Güell, J.L., Manero, F. and Müller, A., 1996. Clear lens extraction to correct high myopia. Journal of Cataract & Refractive Surgery, 22(6), pp.686-689
  21. Lyle, A.W. and Jin, G.J., 1997. Clear lens extraction to correct hyperopia. Journal of Cataract & Refractive Surgery, 23(7), pp.1051-1056
  22. Jiménez-Alfaro, I., Miguélez, S., Bueno, J.L. and Puy, P., 1998. Clear lens extraction and implantation of negative-power posterior chamber intraocular lenses to correct extreme myopia. Journal of Cataract & Refractive Surgery, 24(10), pp.1310-1316
  23. Lee, K.H. and Lee, J.H., 1996. Long-term results of clear lens extraction for severe myopia. Journal of Cataract & Refractive Surgery, 22(10), pp.1411-1415
  24. Barraquer, C., Cavelier, C. and Mejia, L.F., 1994. Incidence of retinal detachment following clear-lens extraction in myopic patients: retrospective analysis. Archives of Ophthalmology, 112(3), pp.336-339

Leave a Reply