Cataract surgery is the most commonly performed procedure in the USA and the United Kingdom and carries a high expectation for visual improvement [1,2,3▪]. Rhegmatogenous retinal detachment (RRD), either in the early or late postoperative period, is an uncommon but serious complication associated with cataract surgery and pseudophakia. The incidence of retinal detachment after cataract surgery has been estimated to range between 0.6 and 1.7% in the first postoperative year and continues over time, with an overall incidence of 0.7% [4–7]. Compared with rates of RRD in the general population of 0.0065–0.0179% [8–11], cataract surgery increases the risk of retinal detachment at least four fold [6,11].
Cataract surgery continues to evolve, with increased surgeon experience and wider adoption of advanced approaches such as topical and intracameral anesthesia, reduced incision size, and multifocal lens technologies. Recently, several large-scale studies have clarified the incidence and risk factors of RRD with current cataract surgery. A recent large retrospective case–control study in Singapore analyzed 24 846 cataract operations performed between 2001 and 2003, with follow-up through 2008, and found a pseudophakic retinal detachment rate of 0.16%, lower than rates previously accepted in the literature. Due to the design of the study, the author included only those cases that required retinal detachment surgery in the same hospital as the cataract surgery; therefore, the rate could be underestimated [12▪▪]. Another retrospective study out of Western Australia looked at 129 982 cataract surgery patients across 46 health facilities in a 21-year period. The overall pseudophakic retinal detachment rate found was 0.7%, consistent with the previously published values [3▪]. This study also found the rate of retinal detachment following cataract surgery decreased dramatically over the study time period from 1980 to 2001, supporting lower rates of pseudophakic retinal detachment in more recent studies [3▪]. However, a prospective cohort study in Taiwan followed 9388 consecutive patients undergoing cataract extraction and intraocular lens implantation from 1999 to 2001 and found a cumulative 8-year retinal detachment rate of 2.31% [13▪▪].
Certain risk factors such as posterior capsular rupture (PCR) and other intraoperative complications have long been identified for pseudophakic retinal detachment. Recent studies confirm these risk factors and further analyze others such as male sex, younger age, myopia and the presence of a posterior vitreous detachment (PVD). This review examines the current evidence to identify and characterize risk factors for RRD following cataract surgery.
Demographic factors such as younger age and male sex have long been known to increase risk of retinal detachment following cataract surgery, and the recent literature continues to support these characteristics as risk factors. In the retrospective series from Singapore, Quek et al.[12▪▪] found the mean age of patients who developed pseudophakic retinal detachment was 55.3 years at the time of initial cataract surgery compared with an average age of 66.9 years in the entire cohort. When comparing younger patients to patients more than 70 years of age, younger patients had significantly higher hazard ratios of retinal detachment (hazard ratio 19.7, P < 0.05). A second large retrospective case–control series of 63 298 cataracts at Moorfield's Eye Hospital in London also found younger age to be a significant risk factor for retinal detachment postoperatively. Mean age in the control group was 71.9 years, whereas mean age in the pseudophakic retinal detachment group was 63.5 years. In addition, the odds ratio comparing patients 64 years and younger to those older than 64 for a poor visual outcome (vision measured at 6/18 or worse) in eyes with retinal detachment was 3.1, with a P = 0.002 [14▪]. The series from Taiwan found the 8-year RRD rate to be 6.65% in patients 50 years or younger, 2.57% in patients between 50 and 60 years, and 2.01% in patients older than 60 years, further evidence that younger age remains a significant risk factor for pseudophakic RRD [13▪▪]. The time course to retinal detachment was variable between these two studies. The study from Moorfield's Eye Hospital found 75% of the retinal detachments were identified within the first two postoperative years, whereas Sheu et al.[13▪▪] found that the mean time interval between cataract surgery to diagnosis of retinal detachment was 40 months [14▪]. The etiology of increased risk in younger patients remains speculative. Changes in the vitreous induced by removal of the crystalline lens are hypothesized to underlie an increased risk of RRD; therefore, the more structurally formed vitreous in younger patients as well as the lack of a PVD may contribute to the increased risk . However, one recent study did not find the postoperative development of PVD in and of itself to statistically increase the rate of pseudophakic RRD .
A male predominance in the pseudophakic retinal detachment group was also noted in the study from Moorfield's [14▪]. In the control group, 38.2% of cataract cases were performed on male patients, whereas 67.5% of the cases in the pseudophakic RRD group were men [14▪]. Sheu et al.[13▪▪] also found male sex to be a risk factor for pseudophakic RRD. The 8-year RRD rate for women in this study was 1.52% compared with 3.28% for men. Male sex has long been associated with an increased risk of RRD, both phakic and pseudophakic, and is not entirely understood . Sheu et al.[13▪▪] hypothesizes an increased and underreported history of trauma in men versus women, however, this has not been substantiated with evidence.
High myopia, defined as axial length greater than or equal to 26 mm, is also an established risk factor for pseudophakic retinal detachment. Numerous recent studies further clarify the risk for pseudophakic RRD in myopia. The retrospective series by Sheu et al.[13▪▪] found an increase in the retinal detachment rate with increasing axial length. An eye with an axial length of 23–25 mm had an 8-year RRD rate of 2.44% compared with 6.14% in eyes greater than or equal to 26 mm. These highly myopic eyes had an adjusted relative risk of 4.19 compared with eyes with axial length of 23 mm or less. A retrospective study by Jeon et al.[17▪] in Korea looked at 347 eyes with high myopia and found the incidence of pseudophakic RRD in this group was 1.72%, compared with a postoperative retinal detachment rate of 0.28% in the control (hyperopic or emmetropic) group. These rates are somewhat low compared with other published studies, however, mean follow-up time in this study was only 7.27 months and the study may not have captured the complete rates of pseudophakic RRD. A third retrospective study from Spain looked at 439 highly myopic eyes with a mean follow-up time of 61.5 months and found an RRD rate of 2.7% . In addition, patients were divided into two groups according to age at the time of surgery. The group with patients aged 50 years or less had an RRD rate of 3.65% compared with a rate of 2.52% in the group with patients aged over 50 years. A trend was found, indicating an association between age at surgery and increased risk of retinal detachment in high myopes .
Zuberbuhler et al. published a series of 156 eyes with extreme myopia, defined as axial lengths greater than 30 mm, undergoing phacoemulsification cataract surgery. The eyes in this study had not had any prior retinal treatments or surgeries, including prophylactic laser treatments. The authors determined a retinal detachment rate of 1.3%. This rate is much lower than other studies looking at highly myopic eyes undergoing cataract surgery [13▪▪,17▪,18]. It is again possible that mean follow-up time (2 years) influenced the lower retinal detachment rate. Sheu et al.[13▪▪] found a trend in their case analysis for a ‘late wave’ of increased retinal detachment after 4 years in patients with axial lengths of more than 26 mm. However, previous literature shows no evidence of a significant late increase in the lens extraction-related incidence of retinal detachment and considers cases of retinal detachment occurring after 4 or more years postoperatively to only be questionably related to the surgery [20–22].
Myopic eyes have a much higher risk of RRD, whether pseudophakic or phakic. One study showed a four-fold increase in spontaneous retinal detachment risk for refractive error of −1.00 to −3.00 D and myopia over −3.00 D was found to have a 10-fold higher risk of retinal detachment . None of the current studies compare retinal detachment rates in age-matched pseudophakic myopic eyes to phakic myopic eyes, therefore, the overall increased retinal detachment risk with cataract surgery has not been established in recent literature. In 2003, Ripandelli et al. published a prospective study comparing eyes of 930 patients with myopia greater than −15.00 D undergoing cataract surgery in one eye and compared RRD rates with the phakic, fellow (control) eye over a 3-year period. Postoperatively, 8% of the operated eyes had pseudophakic RRD compared with a spontaneous RRD rate of 1.2% for the control eyes, suggesting an increased risk with cataract surgery. However, a study by Neuhann et al. looked at 2356 eyes with axial length greater than 27 mm and found the risk of postoperative retinal detachment to be 1.5–2.2%, which was not different than the incidence of idiopathic retinal detachment in phakic myopic eyes.
Another characteristic that likely plays a role in development of retinal breaks and detachments postoperatively is the presence or absence of PVD prior to cataract surgery. The relationship between PVD and RRD is well established. Cataract surgery induces structural and molecular changes in the vitreous body due to the loss of stabilization from the crystalline lens [5,25]. This situation leads to an increased incidence of PVD following cataract surgery, which is confirmed by recent studies . A prospective noncomparative case series of 58 eyes with an absence of PVD on ultrasound preoperatively found that 58.7% of eyes developed a PVD in the year following phacoemulsification surgery, with most of the PVDs developing in the first postoperative month . A second study from New Zealand found that PVD occurs more frequently in eyes that have undergone phacoemulsification cataract surgery as compared with age-matched phakic eyes (50.8% in the surgery group compared to 20.8% in the control group) . However, PVD formation in itself was not found to lead to higher pseudophakic retinal detachment rates in one recent study unless associated with peripheral lattice degeneration . Further work remains to be done to elucidate the interrelationship between younger age, myopia, and PVD formation as risk factors for pseudophakic retinal detachment.
A retrospective study in Wenzhou, China found the cumulative risk of macular hole formation following cataract surgery to be 0.16% in 13 625 eyes studied, with younger age and absence of PVD being the most significant risk factor . Similarly, a small case series of five patients developed acute vitreomacular traction by postoperative day 1 following routine cataract surgery, which resolved over time without surgical intervention . These studies lend further evidence to changes in the vitreoretinal interface leading to increased risk of pseudophakic retinal detachment.
PCR has been isolated as one of the most significant risk factors for pseudophakic retinal detachment. It is postulated that the anterior movement of the vitreous as a result of PCR induces dynamic traction on the vitreous with a consequent retinal tear formation. The study by Quek et al.[12▪▪] discussed previously confirmed a significantly higher rate of PCR in cases that developed retinal detachment postoperatively than in the entire cohort of cataract operations performed (23.1 vs. 2%). Average time for diagnosis of RRD was 15.7 months in this study; however, in cases with PCR there was a mean interval of only 6.6 months from cataract surgery to diagnosis of RRD [12▪▪]. Tuft et al.[14▪] also identify PCR as a risk factor for pseudophakic RRD. In patients with RRD, the rate of PCR without vitrectomy was 4% (compared to 1.1% in controls) and the rate of PCR with vitrectomy was 34.5% in the pseudophakic retinal detachment group (3.6% in controls).
An initiative within the Swedish National Cataract Register set up a study group to investigate, retrospectively, how posterior capsular complications affect risk for subsequent pseudophakic retinal detachment. They collected a cohort of 23 285 cataract surgeries, of which 2.94% had capsular complications. From these patients with capsular complications, a subset was randomly selected to be in the study group. A control group was also randomly selected from the cohort. The 3-year incidence of pseudophakic RRD with capsular complications was 4%, compared with 0.3% in the control group. The difference in RRD frequency between the control and study groups was significant, with an odds ratio of 14.8 at a multiple-factor level. Overall, the authors found more than a 10-fold increase in the risk for RRD after cataract surgery in patients with a capsule complication .
Retinal detachment is one of the most serious complications following cataract surgery, with overall rates of about 0.7%, although recent studies indicate these rates may be declining [3▪,12▪▪]. Younger age and male sex continue to be identified as significant risk factors. High myopia also was found to have higher rates of pseudophakic retinal detachment in recent studies compared with emmetropic controls, although whether these retinal detachment rates are higher than spontaneous retinal detachment rates in this population was not determined. The state of the vitreous preoperatively and postoperatively continues to be an area of research interest. Studies have found the incidence of PVD increases after cataract surgery but the interplay between structural changes in the vitreous and pseudophakic retinal detachment rates have not yet been elucidated. Cataract surgery is the most frequently performed surgery in the USA and the United Kingdom; therefore, even low complication rates can have a significant public health impact.
Conflicts of interest
R.B.B. is a member of the advisory board for Genentech Inc., Allergan Inc., and Alimera Sciences Inc. He is a consultant to Santen Inc. and ActiveSite. The authors have no financial interests related to the topic of this manuscript.
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 73).
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