Pseudophakic retinal detachment: a ticking time bomb : Journal of Cataract & Refractive Surgery

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Pseudophakic retinal detachment: a ticking time bomb

Srinivasan, Sathish FRCSEd, FRCOphth, FACS

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Journal of Cataract & Refractive Surgery 49(3):p 225-226, March 2023. | DOI: 10.1097/j.jcrs.0000000000001157
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It's the little details that are vital. Little things make big things happen.

—John Wooden

Global cataract prevalence has recently been estimated at 17.2% over all age groups, with significant variations by regions and age group.1 The World Health Organization estimates that the number of cases of blindness from cataract will increase to 40 million in 2025 as a result of the aging population and longer life expectancies.2 There is robust evidence to demonstrate that the cataract surgical rate uptake has been on an upward trend.3 Advances in microincision cataract surgery and presbyopia-correcting intraocular lenses (IOLs) have increased in demand for refractive lens exchange (RLE) procedures where the crystalline lens is replaced with custom-matched IOLs to match patient visual needs.4 People worldwide are living longer. Today, most people can expect to live into their sixties and beyond. With every country experiencing growth in both the size and the proportion of older persons by 2030, 1 in 6 people in the world will be aged 60 years or older. At this time, the share of the population aged 60 years and older will increase from 1 billion in 2020 to 1.4 billion.5

Increased life expectancy concomitant with phacoemulsification's enhanced safety and success has galvanized the popularity of cataract surgery and RLE. Retinal detachment (RD) is a vision-threatening condition that has been reported to occur more frequently in pseudophakic eyes than in phakic eyes.6,7 Pseudophakic RD therefore is considered a complication of cataract surgery, with ensuing medicolegal implications.8 Previous studies have reported that the incidence of pseudophakic RD is more frequent in eyes with longer axial length (>25 mm), a history of lattice degeneration or ocular trauma, a history of RD in the fellow eye, younger age (<60 years), male sex, and intraoperative complications such as posterior capsular rupture.9–15

Also, the increased risk of pseudophakic RD is reported not to be confined to the immediate postoperative period but rather maintained over several years because of vitreous alterations after cataract surgery.16 Although the exact mechanism of retinal break formation in pseudophakic RDs remains unclear, multiple theories have been postulated. Nevertheless, it is evident that certain physical and chemical changes occur in the vitreous after cataract surgery predisposing to the formation of retinal breaks. Physical factors that modify the kinetics of the vitreous base include loss of dampening effect of the posterior protuberance of the crystalline lens, forward movement of the vitreous body, and traction on the peripheral retina after vitreous incarceration in the wound.17

Changes in the biochemical microenvironment of the vitreous and retina in pseudophakic eyes are known to occur as a result of lens cortical fibers leaking into the vitreous during cataract surgery.18 These physical and biochemical changes lead to the development of posterior vitreous detachment (PVD) or to the rapid progression of preexisting PVD, leading to retinal tears. Bjerrum et al. in a very elegant study evaluated the risk of pseudophakic RD in a large Danish cohort.19 In this registry-based study of over 200 000 eyes, they analyzed the risk of pseudophakic RD after first-eye phacoemulsification cataract surgery to the relative risk of RD in the fellow nonoperated eyes. The relative risk of pseudophakic RD was 4.23. The risk ratio was not significantly higher in men compared with women (hazard ratio, 1.26), was highest for the 40-year-old cohort and lowest for the 80-year-old cohort, and was highly increased during the first 6 months after but remained significantly elevated up to 10 years after cataract surgery.

In addition, in myopic eyes (>25 mm), there is a 6-fold risk of pseudophakic RD, and this risk is further increased by another 6-fold in younger myopic patients (<60 years).20,21 Putting this in perspective, there is a 12-fold risk of pseudophakic RD in myopes younger than 60 years undergoing lens-based surgery, and this risk is increased by a further 5-fold in cases complicated by posterior capsular tear.20

There is compelling evidence that younger myopes (aged ≤60 years) with axial length greater than 25 mm run a very high risk of developing pseudophakic RD up to 10 years after lens-based surgery, either cataract or RLE. In this issue, Arrevola-Velasco et al. (page 272) in a retrospective chart review analyzed the risk of RD after implantable collamer lens (ICL) implantation in myopic eyes. In this 10-year follow-up study, they showed that the ICL implantation did not increase the risk of RD compared with similar nonoperated myopic eyes. The authors must be credited for these long-term data because there is a paucity of long-term studies on the risk of RD after phakic IOL implantation in myopic eyes.

As media hype and patient demand drive the popularity of cataract and lens-based refractive surgery, we as surgeons should make sure that patients are fully aware of the long-term risks.


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