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Retinal displacement following surgical repair of retinal detachment is a common complication. It involves the repositioning and fixation of the retina in a non-optimal area. Associated risk factors include pars plana vitrectomy as a surgical technique, the use of gas as a tamponading agent, or a retinal detachment involving the macula. Among complementary diagnostic tests, autofluorescence plays a pivotal role, revealing the presence of retinal vessel imprints through the depiction of hyperautofluorescent lines that run parallel to the vessels. These lines represent the original vascular pattern and serve as a distinctive hallmark. Despite the surgical repair of retinal detachment, there is a high incidence of metamorphopsia and visual dissatisfaction among patients suffering from retinal displacement. Several approaches have been proposed to reduce retinal displacement, including the use of a smaller gas bubble as a tamponade, immediate placement of the patient face-down in the operating room, and maintaining this position for at least 2 hours after surgery. In this chapter, we will elaborate on these aspects based on recent literature.
Ophthalmology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
Anselmo Feliciano Sánchez
Ophthalmology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
Paula Boned-Fustel
Ophthalmology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
Laura Fernández García
Ophthalmology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
*Address all correspondence to: dra.garciagil@gmail.com
1. Introduction
The incidence of retinal detachment (RD) ranges from 6.3 to 17.9 per 100,000 inhabitants, with a significant geographic variation [1].
In RD, there is a separation and accumulation of fluid between the retinal pigment epithelium (RPE) and the neurosensory retina due to one or more tears in the retina that allow fluid to pass between these layers. It is considered a cause of visual loss, which can be severe and even lead to permanent visual disability.
There are different types of RD depending on their etiopathogenesis (rhegmatogenous RD, exudative RD, tractional RD). Rhegmatogenous retinal detachment (RRD), caused by a full-thickness retinal tear, stands as the most prevalent form [2].
RPE cells facilitate retinal cohesion by pumping “virtual” subretinal fluid into the choriocapillaris and additionally, to a matrix of proteoglycans called the interphotoreceptor matrix (IPM), which acts as an adhesive intermediary between the neurosensory retina and the RPE, ensuring their connection [2].
The primary pathological process that gives rise to RRD is vitreous syneresis, which involves partial liquefaction of the vitreous gel. This liquefaction can be attributed to various factors, including aging, myopia, which permit the movement of vitreous gel fluid within the eye. Additionally, tractions occurring at vitreoretinal adhesion points, such as the optic disc border and retinal vessels (with stronger adhesions anterior to the equator than posterior), as well as at the vitreous base, can disrupt the cohesive forces between the neurosensory retina and RPE, thereby precipitating retinal tears. This phenomenon allows liquefied vitreous to traverse into the subretinal space in quantities exceeding the pumping capacity of the RPE, resulting in the initiation and subsequent progression of RD [2].
RD damages the neurosensory retina in a characteristic pattern of apoptosis. Photoreceptor cells undergo apoptosis lasting from 1 to 180 days, with the peak occurring at 2 days and the lowest level at 7–14 days. Anatomically, this is expressed by disruption of the outer and inner segments of photoreceptors [3]. Additionally, glial cells undergo anatomical and biochemical changes, such as retraction of synaptic terminals, hypertrophy of Müller cells, and altered expression of certain proteins like the apoptosis-inducing factor [4].
These physiological changes in primary RD sensitize photoreceptors to future apoptotic signals. In cases of recurrent RD, this prior sensitization leads to greater retinal damage compared to that in primary RD [5].
Repositioning of the retina requires surgical treatment, with possible options including scleral buckle (SB) surgery and pars plana vitrectomy (PPV). In cases of localized tears, scleral buckling or pneumatic retinopexy can be used. For cases without localized tears, those with giant tears, lesions with vitreous tractions, or proliferative vitreoretinopathy, PPV emerges as the preferred approach [6].
Scleral buckling constitutes an extraocular surgical procedure involving the application of pressure on the sclera through the placement of a sponge or band at the location of the retinal tear. This indentation effect serves to approximate the sclera to the retina, thereby mitigating vitreous traction on the retinal tissue [2, 7].
PPV, an intraocular surgical procedure, entails the utilization of small-gauge instruments to access the vitreous cavity through the pars plana. This approach facilitates the extraction of the vitreous humor and the rectification of the RD from within. This includes draining the subretinal fluid through the retinal tears, posteriorly sealing the tears using laser or cryopexy, and ocular tamponade employing diverse agents like gas or silicone oil [2, 8].
A noteworthy complication of RD surgical repair is the potential displacement of the retina followed by fixation in an anatomically suboptimal region. This phenomenon can result in structural modifications of photoreceptors and the subsequent manifestation of corresponding visual anomalies.
It has been reported that retinal displacement subsequent to surgical intervention for RD could be observed in a notable proportion of cases, reaching up to 35% as indicated by recent studies [9].
The first description of retinal displacement was presented in 2010 by Shiragami et al., who described hyperautofluorescent lines in the fundus autofluorescence of patients who underwent standard PPV for RRD. These lines ran parallel to the retinal vessels in the area where the RD had occurred [10]. These hyperautofluorescent lines were termed “imprints of retinal vessels,” which perfectly encapsulate the underlying etiology [11].
This chapter provides an update on retinal displacement after retinal surgery and discusses factors to consider during surgery to minimize this complication.
2. Emerging terminology and concepts in retinal repositioning
According to the literature, in the surgical treatment of RRD, achieving complete retinal reattachment after the first surgery is considered a primary anatomical success, and achieving this complete retinal reattachment after multiple surgeries is considered a final anatomical success.
However, these concepts of surgical success only consider the reattachment of the retina in all four quadrants, without considering the quality of that reattachment. This led to the proposal of two new terms in 2020: high-integrity retinal reattachment and low-integrity retinal reattachment (Figure 1) [12].
Figure 1.
Retinal reattachment (illustration created by the author). A: Retinal detachment with fluid between the neurosensory retina and the RPE; B: Image of a high-integrity reattachment, showing proper alignment of photoreceptors in their original position; C: Image of a low-integrity reattachment, depicting poor alignment of photoreceptors in a position different from the original.
High-integrity retinal reattachment is characterized by repositioning the retina as closely as possible to its original location, allowing alignment of photoreceptors as close as possible to their original positions. This achieves better functionality and reduces vertical metamorphopsia [12].
Conversely, low-integrity retinal reattachment involves repositioning the retina far from its original location, without aligning the photoreceptors to their original positions, resulting in poorer functionality.
To assess the integrity of the reattachment, fundus autofluorescence is employed. In cases of high-integrity retinal reattachment, the imprint of retinal vessels will not be observed in autofluorescence. However, in cases of low-integrity retinal reattachment, the imprint of retinal vessels will be evident in autofluorescence imaging.
3. Factors associated with retinal displacement following rhegmatogenous retinal detachment surgery
Several studies have identified factors that can influence the occurrence of retinal displacement, either predisposing to or mitigating the risk of this complication.
Consensus across all studies indicates a heightened risk of retinal displacement in surgeries employing PPV compared to scleral surgery and pneumatic retinopexy. Scleral surgery without the use of tamponade presents the lowest risk of retinal displacement, followed by pneumatic retinopexy [12].
The type of tamponade agent used during surgery also makes a difference, with an increased risk observed in cases involving gas in comparison to silicone oil [13]. Nevertheless, distinctions based on the specific type of gas employed (such as SF6 or C3F8) do not appear to be evident (Table 1).
Flattering displacement
Less displacement
Factors not clearly related to displacement
PPV
Scleral buckling, pneumatic retinopexy
Type of gas
Tamponade gas
Tamponade silicon oil
Initial extension of the RRD
Macula Off
Immediate face-down positioning post-surgery
Use of PFCL
Performing posterior retinotomy
Table 1.
Factors related to retinal displacement after RRD surgery.
PPV: pars plana vitrectomy; RRD: rhegmatogenous retinal detachment; PFCL: liquid perfluorocarbon.
An additional factor under scrutiny in cases of RRD is macular involvement. RRDs that affect the macula demonstrate an increased susceptibility to retinal displacement subsequent to surgical intervention, accompanied by more pronounced visual implications. Conversely, the initial extent of RRD without macular involvement has not been conclusively correlated with retinal displacement [14].
However, a definitive correlation between the utilization of perfluorocarbon liquids (PFCL) to achieve retinal flattening during surgery and the implementation of posterior retinotomy for subretinal fluid drainage, with the occurrence of retinal displacement, has not been firmly established [15].
PPV has emerged as the most common approach in the surgical management of RRD due to technological advancements, refined instrumentation, enhanced visualization systems, its established safety profile, and the achievement of favorable surgical outcomes. Despite surgical efficacy, the occurrence of retinal displacement remains a potential concern.
Within the context of PPV, retinal displacement’s mechanism is attributed to the persistence of a small amount of subretinal fluid immediately after surgery. The large gas bubble injected during PPV generates significant buoyant force and stretches the retina. In this scenario, during the patient’s vertical positioning, the fluid prompts a downward retinal displacement and an anomalous interdigitation of photoreceptors with the retinal pigment epithelium (RPE) [10].
In pneumatic retinopexy, the gas bubble introduced into the vitreous cavity during surgery is smaller than in PPV, resulting in smaller buoyancy force exerted on the retina. This enables gradual subretinal fluid reabsorption by the RPE pump. This gradual reabsorption, combined with face-down positioning followed by vertical positioning, facilitates proper photoreceptor interdigitation with the RPE and thereby contributes to a decreased incidence lower of displacement [12].
In more recent literature, the hypothesis of residual subretinal fluid, strong buoyancy force, and a thin and elastic retina has gained prominence as the mechanism leading to retinal stretching and displacement. This hypothesis aligns with the observation that displacement mainly occurs downward, influenced by gravity and head position.
Conversely, instances of upward retinal displacement have been reported in patients undergoing pneumatic retinopexy, particularly when using silicone oil as a tamponade agent. In pneumatic retinopexy, fluid can be displaced upward during the transition from supine to sitting position in the immediate postoperative period, as some patients remain seated for a few minutes before adopting a face-down position. Similarly, when silicone oil is employed as a tamponade agent, residual fluid can also be pushed upward from its posterior pole position by the pressure exerted by the silicone bubble itself.
Following successful anatomical restoration through surgical retinal detachment repair, there can be cases where patients remain dissatisfied, despite achieving good visual acuity outcomes.
The symptom of distorted lines in the operated eye, known as metamorphopsia, has been strongly associated to retinal displacement in up to 83% of cases [12, 16, 17]. This visual phenomenon is responsible for the visual dissatisfaction experienced by these patients.
On the other hand, several studies have considered decreased corrected visual acuity [14, 16] and alterations in binocular vision due to the perception of an object’s image with different sizes in each eye, known as aniseikonia, as clinical manifestations specific to surgically repaired retinal detachment rather than being solely attributed to retinal displacement [12, 18].
In general, current evidence suggests that metamorphopsia is the only symptom clearly linked to retinal displacement.
Retinal displacement is a complication that remains imperceptible via conventional ophthalmoscopic examination, yet can be readily detected through imaging modalities such as autofluorescence.
Autofluorescence imaging of the fundus has emerged as a prominent non-invasive technique for retinal examination in recent years. It relies on the retina’s ability, as well as its natural fluorophores like lipofuscin, to emit light within the 500–750 nm range upon stimulation by short-wave light.
In the visual cycle, the RPE is responsible for renewing the outer segments of photoreceptors and degrading their constituents (lipids, proteins, fluorophores). However, a fraction of these bioproducts remains unprocessed by RPE lysosomes and accumulates at this level, forming lipofuscin aggregates responsible for the physiological autofluorescence of the retina [10, 19]. Additionally, structures devoid of RPE, such as the optic nerve and retinal vessels, appear dark or hypoautofluorescent in autofluorescence fundus images (Figure 2).
Figure 2.
Normal fundus autofluorescence image. The image depicts the normal autofluorescence of the fundus, highlighting hypoautofluorescent areas (in black), such as the optic nerve and retinal vessels.
This imaging technique allows for the visualization of subtle alterations in retinal layers, including the detection of retinal displacement, which might not be apparent through conventional examination modalities.
In retinal displacement, fundus autofluorescence reveals itself through slightly hyperautofluorescent lines, running parallel to adjacent retinal vessels. These lines accurately reflect the caliber and orientation of these vessels. Such lines correspond to the original imprints of retinal vessels, which have shifted along with the retina following its reattachment (Figures 3 and 4) [13].
Figure 3.
Autofluorescence of retinal displacement. The image displays the hypoautofluorescence of the optic disc, retinal vessels, and the foveal avascular zone. Additionally, the impressions of retinal vessels are evident in the lower retina, attributed to downward displacement after retinal detachment repair with PPV (red arrows).
Figure 4.
Retinal displacement autofluorescence. Postoperative images of a patient who underwent upper rhegmatogenous retinal detachment repair in their left eye using PPV [20]. Impressions of retinal vessels (red arrows), inferior retinal fold (yellow arrow).
There are different theories concerning the genesis of these hyperautofluorescent lines. Some authors suggest that these lines might arise due to heightened metabolic activity within segments of the RPE when exposed to light following retinal displacement [10]. On the contrary, another proposition posits the presence of a distinctive composition and attributes of fluorophores within the RPE cells situated in the region of retinal vessel imprints that were concealed prior to the occurrence of retinal displacement [21].
These hyperfluorescent lines in autofluorescence become visible after RRD surgery once the gas has dissipated and the retina becomes explorable, which is typically around 10 days post-surgery. They maintain their morphological appearance, range, and brightness up to 3 months after surgery [10]. However, starting from 12 months post-surgery, a slight repositioning toward the original vessels can be observed. Thus, the retinal alteration in fundus autofluorescence diminishes over the course of a year following RRD surgical repair [22].
While there is an observed tendency for retinal displacement to gradually resolve over time, conclusive evidence supporting complete reversion remains lacking [9].
Another complementary diagnostic test is optical coherence tomography (OCT), which enables the study of the microstructure of the outer retina in patients with retinal displacement. As previously discussed, retinal displacement leads to an abnormal arrangement of photoreceptors within the interdigitation zones of the RPE. These structural changes can be effectively visualized through OCT imaging.
In a normal OCT scan of the outer retina, four distinct hyperreflective lines are discernible. The first corresponds to the external limiting membrane, the second to the ellipsoids of the photoreceptors, the third to the apical region of the RPE containing phagosomes of the outer segment of the photoreceptors, and the fourth corresponds to mitochondria at the base of the RPE (Figure 5) [23].
Figure 5.
Microstructure of the outer retina. A: Self-created schematic representation; B: Optical coherence tomography (OCT). 1: External limiting membrane, 2: Photoreceptor ellipsoids, 3: Phagosomes of the outer segments of photoreceptors (apical zone of the RPE), 4: Basal region of the RPE.
Patients who exhibit retinal displacement with low-integrity reattachment, as evidenced by alterations in the third line (phagosomes of the outer segments of photoreceptors), experience such alterations in up to 95% of cases. This disruption is accountable for the visual dissatisfaction experienced by these patients (Figures 6 and 7).
Figure 6.
Optical coherence tomography of a patient with retinal displacement. A. Infrared image en face (left), structural OCT (right). B. Structural OCT B-scan: Subfoveal outer retina anomaly.
Figure 7.
Optical coherence tomography of a patient with retinal displacement. A: Outer retinal microstructure. Four hyperreflective lines. 1: External limiting membrane, 2: Photoreceptor ellipsoids, 3: Apical zone of RPE containing phagosomes of outer segments of photoreceptors, 4: Mitochondria at the base of RPE. B. Alteration of subfoveal hyperreflective lines (yellow dashed line).
Prevention of retinal displacement can be addressed through two distinct approaches: during the surgical procedure and in the immediate postoperative phase.
During surgery, several authors propose using a smaller gas bubble as a tamponade than what is conventionally used in both pneumatic retinopexy and PPV. This could facilitate the natural reabsorption of a substantial portion of subretinal fluid, ultimately contributing to a diminished risk of retinal displacement [24, 25].
From the second perspective of the immediate postoperative period, numerous studies agree that performing PPV with gas and immediately positioning the patient in a face-down position in the operating room, maintaining this position for at least 2 hours, can effectively reduce the occurrence of retinal displacement [9].
On the contrary, positions involving a brief period of head elevation or resting supine postures in the immediate postoperative period result in higher rates of retinal displacement. Immediate face-down positioning postoperatively causes the subretinal fluid remaining in the posterior pole to distribute in all directions, not just downward. This is the reason why placing patients face-down after surgery leads to lower rates of retinal displacement. Publications have demonstrated that immediate face-down positioning post-surgery reduces the proportion of patients with retinal displacement from 63.6 to 24.0% [26].
No surgical procedure is exempt from potential complications. In the context of retinal detachment, retinal displacement stands as a frequent complication. Despite achieving anatomical success, the dissatisfaction experienced by patients can pose challenges for surgeons. Recognizing this entity can lead to implementing improvements aimed at mitigating this complication.
The utility of fundus autofluorescence lies in its straightforward, rapid, and secure nature as a diagnostic tool. The identification of retinal vessel imprints renders this technique indispensable for the monitoring of patients who have undergone retinal detachment surgery.
Furthermore, understanding the concept of low-integrity reattachment by vitreoretinal surgeons may lead to further refinements in the techniques employed during vitreoretinal surgery for primary rhegmatogenous retinal detachment repair. This, in turn, may yield improved functional outcomes for patients.
Autofluorescence and optical coherence tomography (OCT) images were obtained using SD-OCT (Spectralis®, Heidelberg Engineering, Heidelberg, Germany).
Nomenclature
RPE
retinal pigment epithelium
PPV
Pars plana vitrectomy
RD
retinal detachment
RRD
rhegmatogenous retinal detachment
OCT
optical coherence tomography
AF
autofluorescence
PFCL
perfluorocarbon liquid
PR
photoreceptors
SB
scleral buckling
SF6
sulfur hexafluoride
C3F8
perfluoropropane
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Written By
Romana García Gil, Anselmo Feliciano Sánchez, Paula Boned-Fustel and Laura Fernández García
Submitted: 31 August 2023Reviewed: 03 September 2023Published: 18 October 2023
Open access peer-reviewed chapter
