Smith JM, Ward LT, Townsend JH, et al. Rhegmatogenous retinal detachment in children: clinical factors predictive of successful surgical repair. Ophthalmology 2019;126:1263-1270.
The literature devoted to pediatric rhegmatogenous retinal detachment (RRD) is relatively scarce, but we know that RRD in children is potentially more challenging to manage than in adults for various reasons, including a higher incidence of abnormal vitreous and retina (such as in retinopathy of prematurity [ROP] or hereditary vitreoretinopathies) and a higher risk of proliferative vitreoretinopathy (PVR). The present study, comprising one of the largest series of pediatric RRDs and spanning a 14-year period at a single tertiary-referral center, aimed to identify factors associated with anatomic and visual outcomes after pediatric RRD repair.
This retrospective case series included RRD patients 0-18 years of age who had at least 3 months’ follow-up. A total of 212 eyes of 191 patients were included, with mean age 10.5 +/- 5 years and mean follow-up of 36 months. The most common predisposing conditions were high myopia, trauma, Stickler syndrome, prior intraocular surgery, and family history of RRD. Patients had a mean 1-2 months of symptoms prior to presentation, 10% of patients presented with bilateral RRD, more than half of patients presented with total RRD, and about 40% of patients presented with grade C PVR.
Successful repair, defined as complete reattachment of the retina with 1 or more operations at the latest follow-up, was achieved in 78% of patients, with a mean 1.34 operations per eye; the single-operation success rate was 65%, with statistically significantly higher rates of success after scleral buckle (SB) alone or in combination with pars plana vitrectomy (PPV), compared to PPV alone. In multivariate analysis, subtotal RRD seemed predictive of successful repair, and previous RRD surgery was predictive of failure. The authors were unable to show an association between successful repair and other factors, including age, PVR, history of trauma, and history of ROP.
By one year postoperatively, two thirds of patients had improved vision compared to baseline, 23% of patients had stable vision, and 11% of patients had worse vision. In most patients, vision improvement continued with each successive visit, but only 21% of patients were 20/40 or better by 1 year.
As with many other RRD studies, the retrospective nature of this study and the heterogeneity of its patients make it difficult to draw specific conclusions regarding the optimal management of pediatric RRD. In addition, it is possible that the study was not adequately powered to detect associations between various patient characteristics, such as PVR, and successful RRD repair. Nonetheless, this study does reinforce several important concepts in pediatric RRD management. First, even with delayed and advanced RRD presentations, most children benefit from prompt surgical repair, as 80% of RRDs can ultimately be repaired and visual acuity can continue to improve even through one year postoperatively. Second, SB should be employed in most cases of pediatric RRD, which makes sense in light of how difficult it can be to completely induce a posterior vitreous detachment and relieve vitreous traction with PPV alone in this population.
Vlad Matei, MD
Denver Retina Center