Discussion
In our population of patients aged 18–50 years, each intervention was found to have favourable visual acuity and safety outcomes, given the proper surgical procedure was selected for treatment. Age less than 30 appears to be a negative prognostic indicator for visual improvement from baseline overall. The overall anatomical success rate was 73.2% without statistical difference among repair procedures.
Evidence-based approach for treatment of primary RRD repair in younger patients remains a challenge as patients under 50 years have traditionally been undersampled in the past surgical outcomes analyses. Various parameters may factor into selection of optimal repair procedure for patients under 50 years of age including the presence or absence of PVD, age, lens status, chronicity of detachment, presence of proliferative vitreoretinopathy, location and number of retinal breaks, surgeon comfort or facilities’ availability. Analysis of our cohort reveals superior baseline visual acuity among patients selected for SB repair versus vitrectomy, which may be related to fewer PVDs in the SB group. Lack of PVD may lead to slower progression of detachment which may delay damage to photoreceptors. IOP and complication rates analyses did not find significant safety differences among PPV, SB, PR or SB–PPV. While efficacy analysis of PR and SB–PPV is limited in this study due to smaller sample sizes (n=13), the overall outcomes in this study appear relatively comparable among the four procedures with the rate of detachment being equivalent if not lower in patients undergoing vitrectomy and combined repair, provided that the proper surgical procedure was selected for treatment. Surgeries planned for RRD in younger patients should be guided based on presenting clinical features rather than age alone.
Our results for patient outcomes are similar to those found in the limited literature comparing these surgical treatment options specifically in patients younger than 50 years of age. The re-detachment rate of 26.7% observed in this study is quite high compared with adults emphasising the worse visual prognosis in younger patients after RRD, but value is similar and consistent with the 33.3% (n=37) anatomic failure rate for primary repair observed in a recent retrospective case series of eyes undergoing retinal detachment repair in patients age 18–40.14
While we did not find a difference in the rate of postoperative cataract formation between SB and vitrectomy, a recent study evaluating surgical outcomes with SB or PPV in younger patients with RRD with a mean age of 33.0±11.8 years reported a higher incidence of postoperative cataracts following PPV while all else was similar.3 A higher proportion of PPV cases in our cohort had already undergone cataract surgery previously, suggesting increased use of this approach when cataract progression is no longer a concern. A recent retrospective study evaluating over 600 eyes found higher anatomical success rates in pseudophakic eyes with PPV alone compared with SB alone, although they did not evaluate these findings in younger patients specifically.17
In comparison to a retrospective analysis evaluating SB versus PPV for RRD repair in patients under 50 years of age from Japan,3 we report similar superior preoperative and final visual acuity in the SB group compared with PPV with similar preference for PPV in patients with macular involvement. In addition, we describe outcomes for PR and SB–PPV repair and find no difference in postoperative visual outcome between SB–PPV versus PPV alone, consistent with the findings in a different previous study looking at RRD repair outcomes in vitrectomy versus combined repairs.18 Notably, however, this study evaluated patients less than 40 years of age. In our study using a cut-off of 50 years of age, we found less postoperative improvement from baseline visual activity for patients less than 30 years of age in comparison to those older than 40 years of age, across all procedures, which would be helpful for counselling patients on visual outcomes. Further separating out this age difference may also allow for identifying other characteristics that need to be taken into consideration for what postoperative outcomes can be expected for individual patients.
Several limitations exist with this study including its retrospective design. As only the small minority of PPV cases occur in younger adults, appropriate sample size remains a challenge in this study considering only about one in eight reviewed charts met criteria for primary RRD repair in a patient aged 18–50 years old. With a total sample size of 86 eyes, our study remains low-powered and warrants future studies of larger sample size to further evaluate outcomes.
Our aim in this study was to characterise a real-world experience for treating retinal detachment in younger patients which may be inherently different from older population. Thus, we chose to include traditionally atypical RRD cases such as Stickler’s patients, traumatic retinal detachment, those with prior globe rupture, vitreous haemorrhage or giant tears in this study in order to provide a practical depiction of the spectrum of retinal detachment in patients between the age of 18 and 50. While these cases may not represent standard primary RRD repair in the general population, we felt inclusion of these cases highlights a unique features and considerations for RRD repair in our cohort, as younger age is typically associated with both higher incidence of traumatic retinal detachments, iant retinal tears, and abnormal vitreoretinal interface.
It is also important to consider that repair selection was made based on individual clinical features of both patient and detachment. While, the decision to perform combined repair over PPV alone may be obvious in certain cases such as in patients with Stickler’s syndrome, the specific clinical features and thought processes contributing to the surgeons’ decision to perform combined SB and vitrectomy versus vitrectomy alone may not always be evident for each specific case in this retrospective review. Further research may continue to explore and compare the available surgical modalities for RRD repair in young patients and evaluate potential contributors to poor outcomes in this group such as high myopia or syndromic retinal detachments.