List of Abbreviations
WHO — World Health Organization
ILM — internal limiting membrane
IOP — intraocular pressure
OD — optic disc
PVD — posterior vitreous detachment
LP — laser photocoagulation
MD — medical devices
PVR — proliferative vitreoretinopathy
PVRD — peripheral vitreoretinal degenerations
RRD — rhegmatogenous retinal detachment
RPE — retinal pigment epithelium
SO — silicone oil
V — vitreous body
US — ultrasound
EPF — electrophysiological studies
** — Vital and Essential Drugs
Terms and Definitions
«White with pressure» is an optical phenomenon in which the color of the fundus changes from its usual orange-red to translucent white or grayish-white when examined with scleral depression.
«White without pressure» has the same appearance, but is detected without applying pressure to the sclera, which, however, allows for a clearer visualization of the whitish lesion and better demarcation of the lesion borders. The detection of these optical phenomena is associated with vitreous traction on the retina at the sites of observed whitening.
Ocular biomicroscopy is a method of intravital visual examination of the optical media and tissues of the eye, based on creating contrast between illuminated and non-illuminated areas, performed using a slit lamp and additional diagnostic lenses (in particular, for fundus biomicroscopy).
Vitrectomy is an endovitreal surgical intervention aimed at removing the vitreous body and eliminating vitreoretinal tractions.
Hemophthalmos is a vitreous hemorrhage, the accumulation of blood in the vitreous body or the vitreous cavity (in aphakia).
Snail-track degeneration is a degeneration similar to lattice degeneration, but lacking obliterated retinal vessels and pigmentation in the affected area.
Vitreous degeneration is an alteration in the structure of the vitreous body (VB) resulting from the disruption of bonds between hyaluronic acid and collagen fibers, leading to liquefaction of the VB (synchisis) and/or syneresis (compounding of the structure), which occurs as a result of many causes: involutional changes, surgical interventions, intraocular inflammation, eye trauma, and others.
Posterior vitreous detachment (PVD) is a process involving a series of physiological changes in the VB that lead to the separation of the posterior cortical layers of the VB from the retina and optic nerve. It is one of the manifestations of involutional age-related changes. If PVD extends to the ora serrata, it can be considered complete.
Optical coherence tomography (OCT) is a non-invasive, contactless diagnostic method for intravital visualization, qualitative and quantitative analysis of the morphological features of fundus structures, based on the principle of light interferometry.
Proliferative vitreoretinopathy (PVR) – a pathological process accompanied by migration, transdifferentiation, and proliferation of various cell types, leading to the formation and growth of fibrous tissue on the surface of the retina, ciliary body, within the vitreous cavity, and subretinally.
Retinal tear is any defect affecting the full thickness of the neurosensory retina. The clinical significance of a tear is that fluid from the vitreous cavity can penetrate into the space between the neurosensory retina and the retinal pigment epithelium (RPE), thereby causing rhegmatogenous retinal detachment (RRD).
Lattice degeneration consists of whitish, intersecting bands forming a lattice pattern in the peripheral retina; reddish areas of retinal thinning, cysts, and pigmentation may occur between the intersections. Histological features include varying degrees of atrophy, irregularity of the inner retinal layers, a pocket of liquefied VB located over the affected area, and VB adhesion to the edges of the lesion.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Rhegmatogenous retinal detachment (RRD) is a pathological condition characterized by the separation of the neurosensory part of the retina from the retinal pigment epithelium (RPE) due to the influx of fluid from the vitreous cavity through a retinal tear into the subretinal space. As a rule, untreated RRD leads to irreversible blindness.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
RRD is one of the most severe diseases, the treatment of which represents an urgent and complex challenge. The development of RRD is directly related to changes in the fibrillar structure of the vitreous body (VB), with the development of synchisis and syneresis, culminating in the formation of incomplete posterior vitreous detachment (PVD) with the appearance of areas of continuous traction, which, in turn, lead to a retinal tear [1,2,3,7,57].
Predisposing factors for the development of RRD include diseases or conditions that promote changes in the VB structure: myopia, aphakia, pseudophakia, trauma, inflammatory and infectious eye diseases, Marfan syndrome, age-related changes (PVD, senile retinoschisis), and peripheral vitreochorioretinal degenerations (PVCRD). Among the latter, the most dangerous are lattice degeneration, snail track degeneration, white-with-pressure and white-without-pressure degenerations, and others [1,4,9,28,30,33,40,83].
The direct condition for the formation of RRD is the appearance of a retinal tear. The tear develops as a result of VB structural disorders accompanied by pronounced contraction of collagen fibers and increased traction forces directed towards the VB base with local full-thickness damage to the retinal structure. Through the retinal tear, fluid enters the subretinal space and detaches the neurosensory retina from the RPE [28,29,31,49].
The disruption of adhesion between the neurosensory retina and the RPE and the formation of RRD are generally attributed to several key pathogenetic factors: VB pathology with the development of anomalous PVD; vitreoretinal traction forming the tear; and gravitational forces that promote the pathological flow of fluid into the subretinal space [5,25,32]. Traction is accompanied by the elevation of the edges of the tear, as a result of which fluid from the vitreous cavity freely penetrates into the subretinal space [31,34,35]. The risk of active tractions is proportional to the degree of mobility of the VB, which increases as its degeneration progresses [28,29,31,35].
1.3 Epidemiology of the Disease or Condition
The social significance and urgency of the problem studied lie in the fact that RRD, being one of the most severe diseases of the visual organ, affects practically all age groups of patients, but is more commonly observed in young, able-bodied individuals [19,27,33]. The prevalence of this disease, according to various authors, is about 10–15 cases per 100,000 population in the general population, and bilateral RRD occurs in 5–30% of cases [1,36,41,43]. In the structure of causes of primary visual disability, retinal detachment accounts for 2 to 9% [27,42]. At the same time, about 89% of patients are of young, working age [37]. According to literature data, untreated RRD leads to irreversible loss of visual functions in 55% of cases, 36% of patients retain correct light projection, and only 9% of patients are able to determine hand motion before the face [27,28,39].
1.4 Features of Coding the Disease or Condition
H33.0 – Retinal detachment with retinal break
1.5 Classification of the disease or condition
I. Modern international classification of retinal detachments and retinal defects (in accordance with the International Classification of Diseases) [1,7,9]:
Rhegmatogenous retinal detachment
Exudative, serous (secondary) retinal detachment
Tractional retinal detachment
Mixed forms of retinal detachment
Retinoschisis and retinal cysts
- Cysts and pseudocysts in the region of the retinal ora serrata
Exceptions: microcystoid retinal degeneration
Retinal defects without retinal detachment
II. By prevalence:
- Total retinal detachment – the retina is detached throughout its entire extent;
- Subtotal retinal detachment – the area of retinal detachment occupies no more than three quadrants;
- Extensive retinal detachment – the area of retinal detachment occupies no more than two quadrants;
- Local retinal detachment – the area of retinal detachment occupies no more than one quadrant.
III. By duration of onset:
- "fresh" (up to 1 month)
- "stale" (from 1 to 3 months)
- "old" (3 months or more)
IV. By mobility:
- mobile
- rigid
V. By height:
- flat
- high
- bullous
VI. By involvement of the macular area:
- without macular involvement (macula on)
- with macular involvement (macula off)
Classification of PVR associated with RRD.
(classification proposed by Machemer et al. in 1991 (Tab. 1) [21]):
Stage A – the vitreous body is turbid, with small pigment clumps and their deposition on the retina, predominantly in the lower parts of the eye cavity; the retina is mobile.
Stage B – wrinkling of the surface of the detached retina, decrease in its mobility, tortuous retinal vessels, rolled-over edge of the retinal tear, relatively immobile vitreous body.
Stage C (posterior) – formation of focal diffuse fixed folds of the retina behind the equator, presence of subretinal strands.
Stage C (anterior) – formation of fixed retinal folds anterior to the equator, displacement of the peripheral retina toward the ciliary body, dense vitreous strands. The severity of proliferation is determined by the volume of retinal pathology and the number of clock hours (1-12), even with non-contiguous proliferations.
The type of membrane contraction is divided into types: 1 (local), 2 (diffuse), 3 (subretinal), 4 (circular), 5 (anterior displacement).
1.6 Clinical presentation of the disease or condition
During mechanical irritation, including rupture and traction of the vitreous body on the retina, the patient develops photopsia. The patient sees "flashes of light" or "lightning" in the area of the visual field opposite to the forming tear when moving the eye or at rest. Such symptoms are precursors to the development of rhegmatogenous retinal detachment (RRD). In a patient with a newly occurred peripheral tear, the visual field is not changed. Upon the formation of retinal detachment, the patient may notice a black shadow at the edge of the visual field. With the progression of the started detachment, the patient complains of a sensation of a "curtain" (from above, below, or from the sides) advancing from the edge of the visual field to its center. In the projection opposite to the tear, distortion of objects (metamorphopsia) and image trembling occur. If the detachment spreads and involves the macular zone, metamorphopsia and a decrease in visual acuity down to light perception are noted. Long-standing retinal detachment leads to complete loss of visual functions of the eye.
When a retinal tear passes through a vessel, hemophthalmos of varying intensity develops: from partial to total. Depending on the degree of hemophthalmos, the patient's complaints may vary from the appearance of opacities, "dots" in the visual field, to a pronounced decrease in vision down to light perception.
With local RRD, especially in the lower half of the fundus, the disease can be asymptomatic for a long time. In RRD with a central tear, the patient may complain of line curvature, object distortion (metamorphopsia), and patients also note the symptom of vision "through a layer of oscillating water".
In RRD, a decrease in IOP by an average of 5 mm Hg is possible. In some cases, RRD occurs with ocular hypertension.
During ophthalmoscopy, the zone of detached retina has a whitish or grayish color, and the choroidal pattern is not differentiated. When moving the eye in cases of fresh detachments, the retina is mobile; in "old" rigid detachments, the retina does not change its configuration. Retinal tears are ophthalmosocopied as bright red defects of various shapes and sizes. Tears can be single or multiple. When tears are localized in the upper half of the fundus, RRD spreads rapidly. RRD slowly progresses in area and can be demarcated by pigment deposition, forming a demarcation line. In long-standing RRDs, the development of secondary degenerative changes is possible, such as pigmented and atrophic foci, intraretinal, and subretinal fibrous changes [7,9,28,83].
2. Diagnostics, medical indications and contraindications for diagnostic methods
In the event of RRD, the diagnosis must be established in the shortest possible time in order to develop patient management tactics and, if indications are present, provide surgical or laser intervention within established timeframes to increase the effectiveness of treatment for this pathology. It is fundamentally important to identify and localize retinal tears to choose the optimal tactics for surgical or laser intervention.
An ophthalmologist verifies the condition according to ICD-10 criteria based on anamnestic data, patient examination, assessment of the clinical picture, and additional examination methods.
The clinical picture is the basis for diagnosing RRD. The symptoms and clinical signs indicated in clause 1.6 are the clinical criteria for establishing this disease: the presence of one or more retinal tears and the accumulation of fluid around them under the retina of any localization and extent with / without vitreous opacification, vitreous hemorrhage, with / without proliferative vitreoretinopathy in the presence of a natural crystalline lens or pseudophakia, established by ophthalmoscopy and confirmed by ultrasound examination of the eyeball in the B-scan variant.
2.1 Complaints and Anamnesis
It is recommended to collect anamnesis and complaints regarding eye pathology in all patients with suspected RRD in order to determine the presence of functional visual disorders [4,7,9,20,28,36,49].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: there may be an absence of complaints for a long time, despite the progression of the disease. Patients with RRD may complain of flashes or photopsia, the "tobacco dust" symptom — floating pigment clumps seen by the patient in the area of the visual field opposite to the forming tear, the presence of newly appeared or enlarged "black dots" or "floaters"; curvature, distortion of objects — metamorphopsia; complaints of a curtain or veil in front of the eye followed by a decrease in vision down to light perception [7,28,49]. From the anamnestic data, it is important to clarify the duration of complaints, the presence of refractive errors in the patient, episodes of heavy physical labor preceding the appearance of complaints, traumatic impacts, previously performed surgical interventions on the organ of vision, as well as the presence of RRD in relatives [59].
2.2 Physical Examination
Physical examination of patients to identify signs of RRD is not used.
2.3 Laboratory Diagnostics
Diagnostic criteria for RRD based on laboratory test data do not exist.
2.4 Instrumental Diagnostics
It is recommended to perform visometry (A02.26.004) with full correction for all patients with RRD at diagnosis and at each follow-up examination to monitor treatment in order to determine the severity of visual disorders [28,36,44,47,48].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform refractometry or determine refraction using a trial lens set (A02.26.013) for all patients with RRD at disease diagnosis, follow-up, and treatment monitoring in order to determine the best-corrected visual acuity for an accurate assessment of the severity of visual disorders [119,120].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform ophthalmotonometry (A02.26.015) (including under local anesthesia using a local anesthetic solution) for all patients with RRD at disease diagnosis, follow-up, and treatment monitoring in order to detect abnormalities in intraocular pressure [28,36,44,47,119].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform eye biomicroscopy (A03.26.001) and fundus biomicroscopy (A03.26.018), and/or examination of the peripheral fundus using a Goldmann three-mirror lens (A03.26.003) or indirect ophthalmoscopy (A02.26.003) of the peripheral retina (if biomicroscopy is impossible or difficult), including under conditions of drug-induced mydriasis, with scleral depression if necessary, in all patients with RRD at all visits in order to identify fundus changes, assess their severity, monitor, and select optimal management tactics [10,36,37,44,48,49,119].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: fundus biomicroscopy with aspheric lenses using a slit lamp (or ophthalmoscopy) is the main method for diagnosing fundus changes in RRD during an ophthalmological appointment under any type (primary health care, specialized care) and condition (inpatient, outpatient) of medical care provision. In RRD patients, it should be performed with a wide pupil (under conditions of drug-induced mydriasis) in the absence of contraindications in the patient. It is important to remember that before pharmacological pupil dilation, the depth of the anterior chamber must be assessed.
Ophthalmoscopy is performed at the slit lamp with the patient sitting at the maximum achievable mydriasis using non-contact diagnostic lenses. To clarify the location of the peripheral tear in complex or unclear cases, a contact three-mirror lens can also be used. In addition, indirect binocular ophthalmoscopy is performed using a high-magnification lens for a detailed examination of fundus structures. At the same time, the preferred patient position is lying on the back, which creates optimal conditions for determining the true boundaries of RRD.
It is customary to start examining the retina from the upper segment in the area of the 12 o'clock meridian, gradually shifting clockwise, examining the entire retina up to the ora serrata. The patient is asked to move their eyes and head to select the optimal position for examination. Subretinal fluid usually spreads according to the direction of gravity, and the RRD configuration is limited to the ora serrata, optic disc, and the primary retinal tear area. Detecting peripheral vitreoretinal chorioretinal degeneration (PVRCD) and retinal tears is an extremely important task. The tactics of surgical treatment for a particular patient will depend on the size, location, configuration of the tears, and the boundaries of the RRD itself.
There are generally accepted rules for finding retinal tears depending on the boundaries of RRD [7,36].
Rule 1: In superior temporal or nasal RRDs, the primary tear in 98% of cases is located within 1.5 hours below the higher border of the detachment;
Rule 2: In superior RRDs crossing the 12 o'clock meridian, or total detachments, the primary tear in 93% of cases is located within a triangle with its apex at 12 o'clock and sides located 1.5 hours away on both sides from 12 o'clock;
Rule 3: In inferior rhegmatogenous retinal detachment (RRD), the tear is located inferiorly between the 9 and 3 o'clock meridians. The detachment is more often flat due to the lesser effect of gravity on subretinal fluid. The higher boundary of the inferior detachment in 95% of cases indicates on which side of the optic disc the tear is located;
Rule 4: In inferior bullous (vesicular) RRD, the retinal tear is located superiorly. Inferior detachments originating from an inferior tear do not have a bullous shape and do not form folds.
Upon completion of the examination, it is recommended to describe the identified changes in the outpatient record, medical history, and/or sketch them on a fundus diagram.
It is recommended to perform ocular ultrasound biometry (A04.26.004) in all patients with RRD to measure biometric parameters of the eye: anteroposterior axis, anterior chamber depth, and lens thickness, in cases where lens replacement is planned during RRD surgery in order to obtain data for accurate calculation of the optical power of the artificial lens [28,36,47,53,119].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended to perform an ultrasound examination of the eyeball (A04.26.002) using the B-scan mode in all patients with RRD at the diagnostic stage of the disease, as well as in case of suspected vitreoretinal interface disorders and membrane status during follow-up and treatment monitoring to assess membrane position and the spatial relationships of intraocular structures [36,45,49,53,96,119].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform static perimetry (A02.26.005) or computer perimetry (A03.26.020) in patients with RRD when an in-depth study of the visual field is necessary during disease diagnosis, follow-up, and treatment monitoring to assess retinal function and visual pathways [36,45,114,119-120].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform an electrophysiological study (registration of electrical sensitivity and lability of the visual analyzer A05.26.003; electroretinography A05.26.001) in patients with RRD when a detailed study of the degree of visual function impairment and determination of the functional prognosis of surgery are necessary to assess retinal function and visual pathways [36,55,56,114,119-120].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: the decision to prescribe other additional diagnostic methods is made based on the results of the baseline examination.
2.5 Other Procedures
It is recommended to perform fundus biomicrophotography using a fundus camera, if technically feasible, in all patients with RRD under conditions of drug-induced mydriasis (using anticholinergics and sympathomimetics, except antiglaucoma drugs S01FB) during disease diagnosis, follow-up, and treatment monitoring for screening, monitoring, and evaluating treatment efficacy [113,119].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the need and frequency of fundus photography using a fundus camera is determined by the ophthalmologist depending on the clinical course of RRD. Fundus photography must be performed with a dilated pupil. Many studies have shown that pharmacological mydriasis significantly improves photograph quality. For this reason, fundus photography is currently recommended to be performed under conditions of drug-induced mydriasis regardless of the type of retinal camera.
It is recommended to perform optical coherence tomography (OCT) of the retina (A03.26.019) under conditions of drug-induced mydriasis, if technically feasible, in patients with RRD and a macular hole or suspected macular hole, as well as when an in-depth assessment of the central retinal area is needed during diagnosis, follow-up, and treatment monitoring for quantitative and qualitative assessment of central retinal pathology and monitoring treatment efficacy [28,44,65,113].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: optical coherence tomography of the retina is recommended to be performed under pharmacological mydriasis, as this significantly improves scan quality.
It is recommended to perform optical coherence tomography angiography (OCT-A) (A03.26.019 in angiography mode) (if technically feasible) under drug-induced mydriasis in patients with RRD when retinal microcirculation impairment in the central fundus is suspected, to detect and monitor changes [50,51,52,65,114].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comments: the need and frequency of OCT-A is determined by the ophthalmologist depending on the clinical course of the disease and concomitant pathology. Optical coherence tomography of the retina using a computerized analyzer (A03.26.019) in angiography mode is recommended to be performed under pharmacological mydriasis, as this significantly improves the quality of the study.
It is necessary to refer patients with concomitant diseases, including systemic conditions and risk factors for various complications, to relevant specialists for consultation prior to laser or surgical treatment in order to identify potential contraindications to these types of treatment and minimize the risk of complications. The choice of specialist (general practitioner, otolaryngologist, dentist, endocrinologist, etc.) is determined based on the concomitant systemic disease and the risk factor for systemic complications [36].
It is recommended to perform chest fluorography (or digital chest fluorography) or chest X-ray (or digital chest X-ray) in all patients with RRD during preparation for surgical treatment or to assess general status, identify concomitant diseases and potential contraindications to these types of treatment, and minimize the risk of complications [8,44-46].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform an electrocardiogram recording in patients with RRD during preparation for surgical treatment to assess general status, identify concomitant diseases and potential contraindications to these types of treatment, and minimize the risk of complications [8].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
It is not recommended to administer conservative treatment to patients with RRD [36,46].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3.2 Laser Treatment
It is recommended to perform focal laser photocoagulation of the fundus (A22.26.009) under local anesthesia (using a local anesthetic solution) in conditions of drug-induced mydriasis for localized peripheral RRD to create chorioretinal adhesion around the retinal tear and the subretinal fluid accumulation zone, preventing fluid spread in the subretinal space and enlargement of the retinal detachment area [100,101,110].
GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)
Comments: in the presence of a retinal tear and subretinal fluid accumulation not exceeding 2 optic disc diameters (peripheral localized RRD), laser treatment may be performed to demarcate the area of subretinal fluid accumulation [84,85,86,87]. It is important to note that the treatment does not reduce the risk of new tears. Parameters of peripheral retinal focal laser photocoagulation (barrier, demarcation): spot diameter 200–500 µm, power is selected individually to obtain grade 2–3 burns, applied in 3–5 rows edge-to-edge or in a checkerboard pattern along the border of the detached retina from all sides [62,63].
Monitoring is performed 2–4 weeks after treatment. In the absence of retinal detachment progression, outpatient follow-up is recommended every 6–12 months. It is recommended to explain potential symptoms of RRD progression to the patient. If clinical symptoms worsen (photopsia, "tobacco dust" sign, newly appeared or increased "black dots" or "floaters"; metamorphopsia; increase in the area of a curtain or veil) and there is a threat of retinal detachment progression involving the macula, consultation with an ophthalmologist is recommended to address the issue of surgical treatment [59,60,86].
3.3 Surgical Treatment
It is recommended to provide timely pathogenetic treatment to all patients with RRD after establishing the diagnosis in order to preserve visual functions [28,111,112].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the patient must be informed about the prognosis of the natural course of the disease without treatment, and about the steady progression of anatomical and functional changes in RRD up to complete vision loss. The patient must understand that the efficacy of RRD treatment depends on the timeliness of surgical and/or laser intervention [102,111,112].
Episcleral surgery
It is recommended to perform circular episcleral buckling (A16.26.082) and (or) local episcleral buckling (A16.26.081) in patients with rhegmatogenous retinal detachment (RRD) to restore normal anatomical relationships and stabilize or improve best-corrected visual acuity [38, 68, 69, 103].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: performed in an operating room; under local anesthesia (using instillation of local anesthetics), if necessary with para- or retrobulbar injection of local anesthetics (if necessary - using combined anesthesia), under medicinal sedation, after treating the skin of the eyelids, the periorbital area and the ocular surface with antiseptics and disinfectants in combination with other drugs used in ophthalmology S01XA (including iodine preparations), using antimicrobial and anti-inflammatory drugs, if necessary with concomitant manipulations, including microinvasive vitrectomy or vitreo-scissoring, intravitreal administration of drugs, air, silicone, tamponade of the vitreal cavity (with an ophthalmic material for temporary replacement of the human vitreous body: a perfluorocarbon compound or another high-molecular compound), intravitreal replacement of the ophthalmic material for temporary replacement of the human vitreous body: perfluorocarbon compound with silicone, removal of silicone oil (or another high-molecular compound) from the vitreal cavity in patients with RRD to restore normal anatomical relationships, stabilize or improve best-corrected visual acuity [38, 68, 69, 103].
Surgical technique:
An incision of the conjunctiva is made at a distance of no more than 4 mm from the limbus, the rectus muscles are isolated and placed on traction sutures, localization of the tear is performed using either indirect binocular ophthalmoscopy, or wide-angle systems built into the operating microscope, or a 3D ophthalmic visualization system (3D ophthalmic visualization system RZN 2017/6557) allowing to obtain a stereoscopic image in real time. Fixation of the episcleral buckle for retinal detachment surgery to the sclera in the projection of the retinal tear is carried out. If indications are present, additional local episcleral buckling, cryopexy of the eye membranes, transscleral drainage of subretinal fluid, transscleral endotamponade with ophthalmic gas, air via pars plana, use of an endoilluminator (FSZ 2012/12246) through a 23-27 G valve port, paracentesis, puncture of the anterior chamber of the eye in case of increased intraocular pressure, installation of an inflatable ophthalmic balloon catheter (FSR 2011/12166) for retinal detachment, pneumatic retinopexy [89, 90] can be performed; in case of reduced transparency of optical media due to lens opacity, ultrasound phacoemulsification with intraocular lens implantation is possible, as well as pars plana 23-27G vitreoretinal surgery if indicated, and other manipulations using an operating ophthalmic microscope, optical devices for fundus visualization (contact or non-contact wide-angle systems), and a 3D ophthalmic visualization system allowing to obtain a stereoscopic image in real time.
Sectoral laser photocoagulation of the retina is mandatory in the postoperative period.
It is recommended to instill medicinal substances into the conjunctival cavity before and after circular and (or) local episcleral buckling in patients with RRD to prevent postoperative complications [70-73, 104, 105, 106, 107].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: instillation of antimicrobial drugs (including antibiotics, fluoroquinolones, and others), antiglaucoma drugs and miotics (in case of increased intraocular pressure), anti-inflammatory drugs (including corticosteroids and nonsteroidal anti-inflammatory drugs), anti-inflammatory drugs in combination with antimicrobial drugs into the conjunctival cavity, if necessary subconjunctival and/or parabulbar injections and/or intramuscular and/or intravenous administration of drugs, injections of systemic antimicrobial drugs (in the absence of medical contraindications), including systemic antibacterial drugs and systemic corticosteroids to prevent postoperative complications [70-73, 104, 105, 106, 107]. The duration of instillations and injections of medicinal substances before and after vitreoretinal surgery is determined based on a comprehensive assessment of the clinical picture of the disease, the course of the operation, and the postoperative period.
It is recommended to remove the episcleral buckle for retinal detachment surgery in patients with RRD when indicated, to eliminate symptoms of buckling material rejection and restore normal anatomical relationships [74, 75].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: performed in an operating room; under local anesthesia (using instillation of local anesthetics), if necessary with para- or retrobulbar injection of local anesthetics (if necessary - using combined anesthesia), under medicinal mydriasis, after treating the skin of the eyelids, periorbital area, and ocular surface with antiseptics and disinfectants, other antimicrobial drugs (including iodine preparations), using antimicrobial and anti-inflammatory drugs, if necessary with concomitant manipulations, including microinvasive vitrectomy or vitreo-scissoring, intravitreal administration of drugs, air, silicone, tamponade of the vitreal cavity (with a perfluorocarbon or other high-molecular compound), intravitreal replacement of the perfluorocarbon compound with silicone, removal of silicone (or another high-molecular compound) from the vitreal cavity [74, 75]. During the removal of the episcleral buckle for retinal detachment surgery, if indicated, additional local episcleral buckling, cryopexy of the eye membranes, conjunctiva, eyelid skin, transscleral endotamponade with ophthalmic gas (Vitreoretinal tamponade FSZ 2008/02532, kit for vitreoretinal gas injection) or air via pars plana, use of an illuminator through a 23-27 G valve port, paracentesis, puncture of the anterior chamber of the eye in case of increased intraocular pressure, installation of an inflatable ophthalmic balloon catheter for retinal detachment, pneumatic retinopexy can be performed; in case of reduced transparency of optical media due to lens opacity, ultrasound phacoemulsification with intraocular lens implantation is possible, as well as pars plana 23-27G vitreoretinal surgery if indicated, and other manipulations using an operating ophthalmic microscope, optical devices for fundus visualization (contact or non-contact wide-angle systems), and a 3D ophthalmic visualization system allowing to obtain a stereoscopic image in real time.
It is recommended to instill medicinal substances into the conjunctival cavity before and after the removal of the episcleral buckle for retinal detachment surgery in patients with RRD to prevent postoperative complications [70-73, 104, 105, 106, 107].
COR CLOE 5Class of Recommendation C (Level of Evidence – 5)
Comments: instillation of medicinal substances into the conjunctival cavity using antimicrobial drugs (including antibiotics, fluoroquinolones, and other antimicrobial drugs), antiglaucoma drugs and miotics (in case of increased intraocular pressure), anti-inflammatory drugs (including corticosteroids and nonsteroidal anti-inflammatory drugs), anti-inflammatory and antimicrobial agents in combination, if necessary subconjunctival and/or parabulbar injections and/or intramuscular and/or intravenous administration of systemic drugs (in the absence of medical contraindications), including systemic antibacterial drugs and systemic corticosteroids to prevent postoperative complications [70-73, 104, 105, 106, 107]. The duration of instillations and injections of medicinal substances before and after vitreoretinal surgery is determined based on a comprehensive assessment of the clinical picture of the disease, the course of the operation, and the postoperative period.
Vitreoretinal surgery
It is recommended to perform microinvasive vitrectomy or vitreosynechiectomy in patients with rhegmatogenous retinal detachment and concomitant indications such as hemophthalmos, proliferative vitreoretinopathy, epiretinal fibrosis, multiple or large peripheral retinal tears, macular hole, etc., in order to restore normal anatomical relationships, stabilize or improve best-corrected visual acuity [76,77,78,79,90,91].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: performed in an operating room using 23–27Ga technology; under local anesthesia (using instillation of local anesthetics), if necessary with para- or retrobulbar injection of local anesthetics (if necessary – with combined anesthesia), under drug-induced mydriasis, after treatment of the skin of the eyelids, periorbital area and ocular surface with antiseptics and disinfectants, other antimicrobial agents (including iodine preparations), if necessary with possible concomitant manipulations, including tamponade of the vitreous cavity with an ophthalmic material for temporary replacement of the human vitreous body: a perfluorocarbon compound or another high-molecular-weight compound, endovitreal replacement thereof with silicone, endovitreal administration of medicinal products, air, silicone, gas (Vitreoretinal tamponade FSZ 2008/02532, kit for vitreoretinal gas injection), endolaser coagulation with a 532 nm ophthalmic laser, episcleral circumferential and (or) local buckling, removal of silicone (or another high-molecular-weight compound) from the vitreous cavity, vitreosynechiectomy, membrane peeling, if necessary in combination with phacoemulsification with intraocular lens implantation or phacoemulsification without intraocular lens.
An ophthalmologist referring a patient for vitreal surgery should consider several factors:
- the severity of pathological changes to predict the functional outcome of the surgery;
- degree of lens opacity for planning staged or combined surgery (microinvasive vitrectomy or vitreosynechiectomy combined with ultrasonic phacoemulsification) for thorough sanitation of the peripheral retina when optical media transparency is reduced;
- in case of vitreous hemorrhage, it is necessary to perform an ultrasound examination of the eyeball to assess the extent of retinal detachment, the mobility of the detached retina, and the presence of choroidal detachment;
- severity of general comorbidities, estimated life expectancy of the patient, and anesthesia risk.
Preparation of the patient for surgery is carried out, if necessary, in conjunction with physicians of other specialties in order to reduce the risk of systemic and local complications [13,16,18,22,23,24,83,93].
To perform microinvasive 23-27G pars plana closed posterior vitrectomy or vitreosynechiectomy, it is necessary to use an ophthalmic surgical system using 23-27Ga sets (preferably 25Ga) for posterior vitrectomy, or combined sets. An operating ophthalmic microscope with magnification, focus, translational movement along two axes (X and Y) and rotational movement (general step, deviation), optical devices for fundus visualization (contact or non-contact wide-angle systems), and a 3D ophthalmic visualization system allowing real-time stereoscopic imaging are used.
A transscleral puncture is made 3–4 mm from the limbus (the distance is marked with the opposite end of the trocar, which has 3 and 4 mm markings) with the placement of 3 or more valved 23-27G ports and an infusion system. For effective treatment of the vitreous body area close to the retinal plane, as well as for the removal of the posterior cortical layers, it is preferable to use vitrectomes whose port is maximally shifted to its distal end. Vitrectomy is performed (removal of the vitreous body up to the ora serrata using a 23-27Ga vitrectome), along with sclerocompression with thorough treatment of the tear edges, aspiration of subretinal fluid (passive or active), endolaser coagulation of retinal tears and areas increasing the risk of recurrence, if necessary using endovitreal administration of medicinal products, air, silicone, ophthalmic gas (Vitreoretinal tamponade FSZ 2008/02532, kit for vitreoretinal gas injection), ophthalmic material for temporary replacement of the human vitreous body: a perfluorocarbon compound (or another high-molecular-weight compound) [108,109].
During microinvasive 23-27G pars plana closed posterior vitrectomy or vitreosynechiectomy, if indicated, membrane peeling, retinotomy, endodiathermocoagulation, placement of a chandelier illuminator through an additional 23-27G port, ultrasonic phacoemulsification with intraocular lens implantation, removal of silicone (or another high-molecular-weight compound) from the vitreous cavity, episcleral circumferential and (or) local buckling, and other manipulations can be performed.
It is recommended to instill medicinal products into the conjunctival sac before and after microinvasive vitrectomy or vitreosynechiectomy in patients with rhegmatogenous retinal detachment to prevent postoperative complications [70-73,104,105,106,107].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: instillation of medicinal products into the conjunctival sac using antimicrobial agents (including antibiotics, fluoroquinolones, and other antimicrobial agents), antiglaucoma drugs and miotics (in case of increased intraocular pressure), anti-inflammatory drugs (including corticosteroids and nonsteroidal anti-inflammatory drugs), anti-inflammatory and antimicrobial agents in combination, if necessary subconjunctival and/or parabutbar and/or intramuscular and/or intravenous injections of systemic antimicrobial agents (in the absence of medical contraindications), including systemic antibacterial drugs and systemic corticosteroids to prevent postoperative complications [70-73,104,105,106,107]. The duration of instillations and injections of medicinal products before and after vitreoretinal surgery is determined based on a comprehensive assessment of the clinical picture of the disease, the features of the surgical course, and the postoperative period.
It is recommended to remove silicone oil (or another high-molecular-weight compound) from the vitreous cavity, if necessary with concomitant manipulations, including repeat tamponade of the vitreous cavity with an ophthalmic material for temporary replacement of the human vitreous body: a perfluorocarbon compound or another high-molecular-weight compound, endovitreal replacement thereof with silicone, endovitreal administration of medicinal products, air, silicone, gas (Vitreoretinal tamponade FSZ 2008/02532, kit for vitreoretinal gas injection), endolaser coagulation, endodiathermocoagulation in patients with previously operated rhegmatogenous retinal detachment, in the long-term period after microinvasive vitrectomy or vitreosynechiectomy, in order to prevent complications associated with excessively prolonged silicone oil endotamponade [80,81,82].
Level of Recommendation Consensus CLevel of Evidence 4Level of recommendation consensus C (level of evidence – 4)
Comments: performed in an operating room; under local anesthesia using instillation of local anesthetics, if necessary with para- or retrobulbar injection of local anesthetics, if necessary using combined anesthesia; under drug-induced mydriasis, after treatment of the eyelid skin, periorbital area, and ocular surface with antiseptics and disinfectants, other antimicrobial agents (including iodine preparations) using antimicrobial and anti-inflammatory agents [80,81,82].
The duration of silicone oil endotamponade of the vitreous cavity is determined by the physician based on the results of patient monitoring. The decision to complete silicone tamponade is made based on the evaluation of the following factors:
complete retinal attachment for at least 1 month;
absence of signs of proliferative activity;
absence of tractional forces on the retina;
complete blocking of old retinal tears and absence of new ones;
stable, pigmented, well-defined laser scars;
normal intraocular pressure;
degree of silicone oil emulsification, etc.
During the removal of silicone oil from the vitreal cavity, a 23–27G pars plana trocar system is used (valved ports are preferred); membrane peeling, retinotomy, 532 nm endolaser retinopexy, endodiathermocoagulation, endovitreous administration of medications, air, silicone, or gas (vitreoretinal tamponade FSZ 2008/02532, gas kit for vitreoretinal injection), vitreal cavity tamponade (using an aqueous humor/vitreous body fluid substitute, intraoperative), installation of a chandelier illuminator via an additional 23–27 Ga port can be performed. In case of reduced transparency of optical media due to lens opacity, ultrasonic phacoemulsification with intraocular lens implantation and other manipulations using an ophthalmic operating microscope, optical fundus visualization devices (contact or non-contact wide-angle systems), and a 3D ophthalmic visualization system allowing real-time stereoscopic imaging may be performed.
It is recommended to instill medications into the conjunctival sac before and after the removal of silicone oil (or another high-molecular-weight compound) from the vitreal cavity in patients with RRD to prevent postoperative complications [70-73,104,105,107].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: conjunctival instillation of medications using antimicrobial agents (including antibiotics, fluoroquinolones, and other antimicrobial agents), antiglaucoma medications and miotics (in case of elevated intraocular pressure), anti-inflammatory drugs (including corticosteroids and nonsteroidal anti-inflammatory drugs), or a combination of anti-inflammatory and antimicrobial agents, if necessary, supplemented by subconjunctival and/or parabulbar and/or intramuscular and/or intravenous injections of systemic antimicrobial agents (in the absence of medical contraindications), including systemic antibacterial drugs and systemic corticosteroids for the prevention of postoperative complications [70-73,104,105,107]. The duration of drug instillations and injections before and after vitreoretinal surgery is determined based on a comprehensive assessment of the clinical picture of the disease, the course of the surgery, and the postoperative period.
It is recommended to restrict the detached retina zone with coagulates and/or achieve partial/complete anatomical attachment of the retina by the time of discharge from the hospital in patients with RRD [7,9,32,37,91].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3.4. Other Treatment
Not applicable.
Dietary therapy is not used.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended to select spectacle correction for vision (individually packaged or unpackaged corrective glasses) in patients with low vision to improve visual functions, quality of life, and social adaptation [64,65,91,97].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: for full psychological rehabilitation, the patient must be warned before surgery about the slow improvement of vision in the postoperative period. During long-term follow-up after successful RRD surgery, visual acuity may reach maximum values within 5 years or more after treatment [39,97]. If adequate and timely treatment is available, early motor rehabilitation is recommended for patients with RRD [66].
5. Prevention and Dispensary Observation
It is recommended to ensure timely diagnosis of peripheral vitreochorioretinal degenerations in patients with PVCRD and to identify other predisposing factors for RRD [59].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform focal laser photocoagulation of the fundus (A22.26.009) in the presence of peripheral vitreochorioretinal degenerations in patients with PVCRD, retinal breaks, and other predisposing factors for RRD [59].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform a follow-up ultrasound examination of the eyeball (A04.26.002) using B-scan in patients with hemophthalmos as a risk factor for RRD development, in order to detect a retinal break [36,120].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the frequency of examinations and ultrasound imaging in hemophthalmos is determined individually by an ophthalmologist, depending on the course of the process. Outpatient monitoring until the resolution of hemophthalmos is also performed for patients at risk for RRD: with myopia of any degree; in the absence of a history of retinal vascular pathology (diabetic retinopathy, age-related macular degeneration, venous occlusion); with eye trauma; with retinal detachment in the fellow eye; with aphakia/pseudophakia and other pathology for up to 3 months [3]. If a retinal break is detected, the patient must be examined by an ophthalmologist to determine the feasibility and possibility of surgical intervention [11].
It is recommended to schedule a dispensary follow-up visit (examination, consultation) with an ophthalmologist within the first month after surgery, and subsequently every 6–12 months for all patients with RRD to detect and assess the severity of retinal changes, monitor them, and develop a management strategy. The duration of follow-up is determined by the attending physician taking into account the postoperative ophthalmic status [67].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: the ophthalmologist examines postoperative patients one or more times during the first month after treatment, taking into account the postoperative ophthalmic status; subsequent monitoring is carried out by the local ophthalmologist once every 6–12 months after treatment to track potential late complications [67]. In addition to standard control parameters, it is necessary to monitor for signs of rejection of the sterile silicone band used for surgical treatment of retinal detachment (in cases of episcleral surgery) and signs of silicone emulsification (in cases of vitreoretinal surgery). In case of an unexpected decrease in visual acuity or the appearance of any complaints from the organ of vision, an examination by an ophthalmologist should be performed as soon as possible, regardless of the scheduled visit date.
To determine patients' subjective satisfaction with treatment outcomes, various assessment tools can be used, in particular the National Eye Institute Visual Function Questionnaire (NEI-VFQ 25) (Appendix G1-GN) [116,118].
6. Organization of Medical Care
Issues regarding the organization of medical care for RRD are primarily related to the timeliness of diagnosis and the possibility of performing early treatment before the development of macular detachment. The methods and timing of medical care depend on the type of rhegmatogenous retinal detachment. Criteria for choosing the management strategy for RRD patients are specified in Table 4 of Appendix A3 [88,92,94].
Primary specialized health care is provided by an ophthalmologist in the outpatient department of a medical organization.
Treatment (laser interventions, episcleral surgery, or vitreoretinal surgery) is performed by an ophthalmologist on an outpatient basis, in a day hospital setting, or in an inpatient setting. The basis for discharging a patient from a medical organization is the complete completion of the planned treatment.
Indications for planned hospitalization in a medical organization:
the need to perform surgical interventions in a day hospital or inpatient setting.
Indications for emergency hospitalization to a medical organization:
endophthalmitis as a complication of vitreoretinal intervention [14].
Indications for patient discharge from a medical organization:
1) completion of treatment or a stage of specialized, including high-tech, medical care in an inpatient or day-care setting, provided there are no treatment complications requiring drug correction and/or inpatient medical interventions;
2) refusal of the patient or their legal representative from specialized, including high-tech, medical care in an inpatient or day-care setting;
3) need to transfer the patient to another medical organization.
7. Additional Information
In the postoperative period, it is necessary to explain to the patient the recommended frequency of examinations by an ophthalmologist depending on the severity of the clinical picture, as well as the need for unscheduled examinations if any new visual disturbances appear.
In cases of irreversible blindness or low vision, the patient must be fully informed about the opportunities for vocational, social, and psychological rehabilitation.
In case of retinal laser photocoagulation, the following points must be discussed with the patient:
- the need for repeat examinations and, if necessary, additional laser or surgical treatment;
In case of episcleral and vitreoretinal surgery, the following points must be discussed with the patient:
- it is important to warn the patient about the specifics of the postoperative course and possible ocular manifestations (irritation, eye redness, pronounced eyelid edema combined with abundant discharge, eye pain, foreign body sensation behind the eyelids or discomfort when blinking, etc.), the severity of which depends on the specifics of the performed surgery, as well as the individual sensitivity of the body to the surgical trauma.
- it is important to explain to the patient that temporary glasses or contact lenses may be required during the rehabilitation period; final spectacle correction should ideally be performed no earlier than 2-3 months after surgery (the timing of glasses selection is determined individually).
- in the presence of complaints and changes characteristic of RRD in the operated eye, the patient must be informed of the need for an unscheduled examination by an ophthalmologist.
- it is important to explain that vision will improve gradually in the postoperative period, and that as vision recovers, patients may experience complaints of distorted lines and objects, as well as double vision (typically, these symptoms subside gradually over several weeks or months).
- it is important to warn the patient about adhering to the prescribed regimen (specific head positioning, temporary activity restrictions, specific bed rest requirements) after surgery, which may have a specific therapeutic significance. Individual recommendations should be clarified during the medical consultation.
- it is important to warn patients of the need to immediately report symptoms that may suggest intraocular inflammation (endophthalmitis): eye pain or increased discomfort in the eye, increased eye redness, blurred or decreased vision, increased light sensitivity, or an increase in the number of "floaters" in the visual field.
Criteria for Evaluating the Quality of Medical Care
No. | Quality criteria | Evaluation of compliance |
|---|---|---|
1. | Visometry was performed | Yes/No |
2. | Ophthalmoscopy and/or fundus biomicroscopy was performed | Yes/No |
3. | B-scan ultrasonography of the eyeball was performed | Yes/No |
4. | Static / automated perimetry was performed | Yes/No |
5. | Focal laser photocoagulation of the fundus and/or surgical intervention was performed (depending on medical indications and in the absence of medical contraindications) | Yes/No |
6. | Therapy was administered using antimicrobial drugs (including antibiotics, fluoroquinolones, and other antimicrobials), antiglaucoma medications and miotics (in case of elevated intraocular pressure), anti-inflammatory drugs (including corticosteroids and nonsteroidal anti-inflammatory drugs), anti-inflammatory and antimicrobial agents combined when necessary, subconjunctival and/or parabulbar and/or intramuscular and/or intravenous injections of systemic antimicrobials, including systemic antibacterial agents and systemic corticosteroids for the prevention of postoperative complications (depending on medical indications and in the absence of medical contraindications) as part of preoperative preparation and postoperative patient management | Yes/No |
7. | The area of detached retina was delimited with coagulates and/or partial or complete anatomical retinal attachment was achieved by the time of hospital discharge in patients with rhegmatogenous retinal detachment | Yes/No |
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Appendix A1. Working Group Composition
Tatyana Andreevna Avanesova – PhD in Medical Sciences, Federal State Budgetary Institution "Central Clinical Hospital with Polyclinic" of the Presidential Administration of the Russian Federation |
|---|
Dmitry Gennadievich Arsyutov – PhD in Medical Sciences, General Director of the S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health |
Yaroslav Vladimirovich Bayborodov – PhD in Medical Sciences, Head of the Surgical Department at the Saint Petersburg Branch of the S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health, Associate Professor at the Department of Ophthalmology, North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health |
Ernest V. Boyko - D.Sc. (Medicine), Professor, Corresponding Member of the Military Medical Academy, Director of the St. Petersburg Branch of the S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health, Head of the Department of Ophthalmology at the North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health |
Ilya M. Gorshkov - Ph.D. (Medicine), Head of the Vitreoretinal Department, S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health |
Olga V. Zaitseva - Ph.D. (Medicine), Deputy Director for Organizational and Methodological Work, National Medical Research Center "Helmholtz National Medical Research Center of Eye Diseases" of the Ministry of Health of the Russian Federation, Leading Researcher at the Retinal Pathology Department, Executive Director of the Association of Ophthalmologists |
Viktor N. Kazaikin - D.Sc. (Medicine), Head of the Vitreoretinal Surgery Department, Ekaterinburg Center of Eye Microsurgery JSC |
Svetlana V. Kolesnik - Ph.D. (Medicine), Researcher at the Vitreoretinal Surgery and Diabetic Eye Department, S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health |
Leonid A. Kryl - Ph.D. (Medicine), Senior Researcher at the Retinal Laser Surgery Department, S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health |
Aleksey N. Kulikov - D.Sc. (Medicine), Head of the Department (Head of the Clinic) of Ophthalmology, S.M. Kirov Military Medical Academy - Chief Ophthalmologist of the Ministry of Defense of the Russian Federation |
Alexander V. Malafeev - Ph.D. (Medicine), Ophthalmologist at the Vitreoretinal Department of the Krasnodar Branch, S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health |
Vladimir V. Neroev - D.Sc. (Medicine), Professor, Director of the Helmholtz National Medical Research Center of Eye Diseases of the Ministry of Health of the Russian Federation, Head of the Department of Eye Diseases of the Faculty of Additional Professional Education, Academician of the RAS, Chief Freelance Ophthalmologist of the Russian Ministry of Health, President of the Association of Ophthalmologists |
Denis V. Petrachkov - Ph.D. (Medicine), Research Institute of Eye Diseases |
Alexander N. Samoylov - D.Sc. (Medicine), Professor, Head of the Department of Ophthalmology, Kazan State Medical University |
Svetlana V. Sdobnikova - Ph.D. (Medicine), Senior Researcher, Medical Research and Educational Center of Lomonosov Moscow State University |
Sergey D. Stebnev - D.Sc. (Medicine), Professor at the Department of Eye Diseases, Institute of Postgraduate Education, Samara State Medical University of the Russian Ministry of Health, Chief Physician of Eye Surgery LLC, Samara |
Georgy E. Stolyarenko - D.Sc. (Medicine), Professor, General Director of the Center for Diagnosis and Surgery of the Posterior Segment of the Eye LLC, Moscow |
Oleg V. Unguryanov - Ph.D. (Medicine), Spektr Eye Clinic |
Rinat R. Faizrakhmanov - D.Sc. (Medicine), Head of Department, Pirogov National Medical and Surgical Center of the Ministry of Health of the Russian Federation, Board Member of the Society of Ophthalmologists of Russia |
Alexander Yu. Khudyakov - Head of the Department of Retinal and Vitreous Surgery, Khabarovsk Branch of the S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health |
Dmitry V. Chernykh - Ph.D. (Medicine), 1st Ophthalmological Department of the Novosibirsk Branch of the S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health |
Mikhail M. Shishkin - D.Sc. (Medicine), Professor, Ophthalmologist (Chief Specialist), Pirogov National Medical and Surgical Center of the Ministry of Health of the Russian Federation, Member of the Presidium of the Board of the Society of Ophthalmologists of Russia |
Dmitry O. Shkvorchenko - Ph.D. (Medicine), Deputy Chief Physician for Medical Affairs, S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health |
Nina N. Yudina - Ph.D. (Medicine), Head of the Vitreoretinal Surgery Department, Kaluga Branch of the S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health |
Alexey P. Yakimov - Ph.D. (Medicine), Deputy Director for Clinical Work, Irkutsk Branch of the S.N. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Chief Ophthalmologist of Irkutsk, Assistant at the Department of the Irkutsk State Medical Academy of Postgraduate Education |
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Ophthalmologists;
General practitioners (family physicians);
Medical students, residents, and postgraduate students.
Methods used for evidence collection/selection: searches in electronic databases; analysis of current scientific developments on rhegmatogenous retinal detachment in Russia and abroad; synthesis of practical experience of Russian and foreign specialists. Description of methods used for evidence collection/selection: the evidence base for the recommendations includes publications from the Cochrane Library, EMBASE and MEDLINE databases, as well as monographs and articles in leading specialized peer-reviewed domestic medical journals on the subject. Methods used for quality and strength of evidence assessment: expert consensus, significance assessment according to a rating scale.
Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic review of randomized clinical trials using meta-analysis |
2 | Individual studies with reference standard control or individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials, using meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials using meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Levels of Evidence (LE) rating scale for prevention, diagnostic, treatment and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The clinical guidelines update mechanism provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Current instructions for medicinal products mentioned in these clinical guidelines are published on the website http://grls.rosminzdrav.ru. Order of the Russian Ministry of Health No. 80n dated February 9, 2016 (as amended on March 17, 2025) "On Approval of the Procedure for Maintaining the State Register of Medicinal Products for Medical Use".
These clinical guidelines were developed taking into account the following documents:
Order of the Ministry of Health of the Russian Federation No. 558n dated June 9, 2020 "On Amending the Procedure for Providing Medical Care to the Adult Population with Diseases of the Eye, Its Adnexa and Orbit", approved by Order of the Ministry of Health of the Russian Federation No. 902n dated November 12, 2012."
International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) (World Health Organization) 1994.
Order of the Russian Ministry of Health No. 804n dated October 13, 2017 "On Approval of the Nomenclature of Medical Services" (as amended on September 24, 2020, with amendments dated October 26, 2022) "On Approval of the Nomenclature of Medical Services".
Federal Law No. 323-FZ dated November 21, 2011 (as amended on December 28, 2024) "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation" (with amendments and additions, effective July 1, 2025).
Order of the Russian Ministry of Health No. 902n dated November 12, 2012 (as amended on February 1, 2022) "On Approval of the Procedure for Providing Medical Care to the Adult Population with Diseases of the Eye, Its Adnexa and Orbit".
Order of the Russian Ministry of Health No. 205n dated May 2, 2023 (as amended on December 4, 2023) "On Approval of the Nomenclature of Positions of Medical and Pharmaceutical Workers".
Order of the Government of the Russian Federation No. 2406-r dated October 12, 2019 (as amended on January 15, 2025), "On Approval of the List of Vital and Essential Medicines, as well as Lists of Medicinal Products for Medical Use and the Minimum Assortment of Medicinal Products Required for Medical Care."
Management of Planned Hospitalization in a Multidisciplinary Hospital. Methodological Recommendations No. 2001/144 (approved by the Ministry of Health of the Russian Federation on November 9, 2001).
Order of the Ministry of Health and Social Development of the Russian Federation No. 786n dated December 29, 2008 (as amended on December 7, 2009) "On the Procedure for Formation and Approval of the State Assignment for the Provision of High-Tech Medical Care to Citizens of the Russian Federation at the Expense of Federal Budget Allocations in 2009" (together with the "Procedure for Referring Citizens to Medical Institutions for the Provision of High-Tech Medical Care within the Framework of the State Assignment for the Provision of High-Tech Medical Care to Citizens of the Russian Federation at the Expense of Federal Budget Allocations in 2009").
Table 4. Criteria for selecting management tactics for patients with rhegmatogenous retinal detachment
Severity of lesion | Management tactics |
|---|---|
No rhegmatogenous retinal detachment, presence of peripheral vitreoretinal degeneration or retinal tear | Focal laser photocoagulation of the fundus around the tears is recommended in the cases listed in the "Prevention" section of these clinical guidelines (p. 29). |
Presence of a retinal tear and accumulation of subretinal fluid around it not exceeding 2 optic disc diameters | Focal laser photocoagulation of the fundus and dynamic monitoring of the patient aimed at detecting factors of rhegmatogenous retinal detachment progression (increased vitreoretinal traction, formation of new retinal tear(s), increase in retinal detachment area, vitreous hemorrhage, proliferative vitreoretinopathy) are recommended. |
Rhegmatogenous retinal detachment with single or multiple peripheral tears within one or more quadrants, subtotal and total retinal detachment, rhegmatogenous retinal detachment with a tear at the ora serrata without severe proliferative vitreoretinopathy and edge rolling, with a clear native lens. | Extra-scleral surgery / vitreoretinal surgery (at the discretion of the ophthalmologist) and dynamic monitoring of the patient aimed at detecting factors of rhegmatogenous retinal detachment progression (incomplete retinal reattachment, formation of new retinal tear(s), vitreous hemorrhage, proliferative vitreoretinopathy) are recommended. |
RRD with single or multiple peripheral tears located within one or several quadrants, situated at the same or different distances from the ora serrata, in combination with a peripheral and macular tear, giant tear, subtotal and total retinal detachment, RRD with/without detachment from the ora serrata and inversion of the retinal edge, RRD with vitreous opacity, vitreous hemorrhage, RRD with pronounced proliferative vitreoretinopathy in the presence of a preserved natural crystalline lens or pseudophakia. | Vitrectomy / vitreoschisis surgery and patient follow-up aimed at identifying factors contributing to RRD recurrence (non-attachment of retinal detachment, formation of new retinal tear(s), formation of epiretinal / subretinal membranes, proliferative vitreoretinopathy). |
(after treatment) | Patient follow-up is recommended, aimed at identifying factors contributing to RRD recurrence (non-attachment of retinal detachment, formation of new retinal tear(s), formation of epiretinal / subretinal membranes, proliferative vitreoretinopathy). |
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Nowadays, medicine is paying increasing attention to informing patients and their families about diseases. A lack of information, insufficient awareness regarding treatment options, recommended timelines for surgical interventions, and potential complications can cause various emotional reactions such as anxiety, reactive depression, and conflict behavior, which may lead to non-compliance with medical prescriptions and recommendations, and subsequent dissatisfaction with the treatment received.
Rhegmatogenous retinal detachment (RRD) is a severe vision-threatening condition and a significant biomedical and social problem due to the challenges in treatment and rehabilitation of patients, its prevalence among working-age individuals, and the likelihood of recurrence. Without timely laser / surgical treatment, it can lead to low vision and blindness. Over time, RRD tends to spread. The rate of RRD spread is influenced by the size and location of the tear, as well as the state of the vitreous body. Predisposing factors for the development of RRD include conditions accompanied by changes in the vitreous structure: myopia, aphakia, pseudophakia, trauma, inflammatory and infectious eye diseases (cytomegalovirus infection, toxoplasmosis), Marfan syndrome, age-related changes, and others.
International practical experience has demonstrated that a timely clinical diagnosis and appropriate surgical treatment for this pathology ensure a favorable prognosis and the preservation of visual function quality. The patient should be aware that laser treatment may require repeated treatment sessions, the frequency and scope of which are determined by the physician.
Following the surgical intervention, the patient will be instructed on the specifics of the rehabilitation period and the recovery of visual functions. They are advised to continue treatment on an outpatient basis, which includes instillation of medications to prevent inflammatory phenomena in the organ of vision. The patient should follow the prescribed regimen (specific head positioning, temporary activity restrictions, specific bed rest requirements) after surgery, which may have significant therapeutic value. Individual recommendations should be clarified during a medical consultation. Patients who have undergone surgery for RRD should be informed about strict restrictions on physical activity, visiting bathhouses or saunas for a month post-surgery, and engaging in sports for a month post-surgery; a slight expansion of physical activity may be possible later, only after consultation with the attending physician. In the postoperative period, the patient will be instructed on the recommended frequency of ophthalmologist examinations depending on the severity of the clinical picture, as well as the necessity of unscheduled examinations upon the appearance of any new visual disturbances. The patient must strictly follow all medical recommendations.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix G1. National Eye Institute Visual Function Questionnaire
Russian title: National Eye Institute Visual Function Questionnaire
Original title (if available): The National Eye Institute Visual Function Questionnaire (NEI-VFQ 25)
Source (official developer website, validation publication): [116,118]
Type (underline):
rating scale index questionnaire
other (specify):
Purpose: patient's subjective assessment of visual functions
Assessment tool, content:
Russian-language version of the NEI-VFQ 25 questionnaire:
In general, would you say your health is:
excellent.........................1
very good...................2
good..............................3
fair..........................4
poor................................5
At present, would you say your vision in both eyes (using glasses or contact lenses, if you use them) is excellent, good, fair, poor, very poor?
excellent.........................1
good..............................2
fair..........................3
poor.................................4
very poor......................5
completely blind.............6
How often do you worry about your eyesight?
never............................................ 1
rarely............................................... 2
sometimes............................................. 3
often............................................... 4
constantly....................................... 5
How severe is the pain or discomfort you experience in or around your eyes (e.g., burning, itching, or aching)?
none....................... 1
mild................. 2
moderate.......................... 3
severe.............................. 4
very severe.................... 5
How difficult is it for you to read ordinary newspaper print?
not at all difficult....................................................... 1
a little difficult......................................................... 2
quite difficult....................................................... 3
extremely difficult................................................. 4
stopped doing this due to vision......................... 5
stopped doing this for other reasons
or have no interest in it.............................. 6
How difficult is it for you to perform activities or hobbies that require:
good near vision: cooking, sewing, minor home repairs, or using hand tools?
not at all difficult....................................................... 1
a little difficult.......................................................... 2
quite difficult........................................................ 3
extremely difficult.................................................. 4
stopped doing this due to vision.......................... 5
stopped doing this for other reasons
or have no interest in it............................... 6
Because of your vision, how difficult is it for you to find something on a shelf cluttered with various items?
not at all difficult...................................................... 1
a little difficult...........................................................2
quite difficult.........................................................3
extremely difficult.................................................. 4
stopped doing this due to vision.......................... 5
stopped doing this for other reasons
or have no interest in it............................... 6
How difficult is it for you to read street signs, street names, or store names?
not at all difficult........................................................ 1
a little difficult........................................................... 2
moderately difficult......................................................... 3
extremely difficult................................................... 4
stopped doing this because of eyesight........................... 5
stopped doing this for other reasons
or have no interest in doing so................................ 6
Because of your vision, how difficult is it for you to step down stairs, steps, or curbs in dim lighting or at night?
not at all difficult....................................................... 1
a little difficult.......................................................... 2
quite difficult........................................................ 3
extremely difficult................................................. 4
stopped doing this because of eyesight........................ .5
stopped doing this for other reasons
or have no interest in it.............................. 6
Because of your vision, how difficult is it for you to notice objects to the sides while walking?
not at all difficult.......................................................1
a little difficult..........................................................2
moderately difficult........................................................3
extremely difficult................................................. 4
stopped doing this because of eyesight..........................5
stopped doing this for other reasons
or have no interest in it.............................. 6
Because of your vision, how difficult is it for you to see how people react to what you say to them?
not at all difficult...................................................... 1
a little difficult.......................................................... 2
quite difficult........................................................ 3
extremely difficult.................................................. 4
stopped doing this due to vision.......................... 5
stopped doing this for other reasons
or have no interest in doing so.................................6
Because of your vision, how difficult is it for you to choose your clothes and match clothing items that go together?
not at all difficult...................................................... 1
a little difficult......................................................... 2
quite difficult....................................................... 3
extremely difficult................................................. 4
stopped doing this due to vision......................... 5
stopped doing this for other reasons
or have no interest in it.............................. 6
Because of your vision, how difficult is it for you to interact with people when visiting others?
not at all difficult...................................................... 1
a little difficult......................................................... 2
moderately difficult........................................................3
extremely difficult................................................. 4
stopped doing this due to vision......................... 5
stopped doing this for other reasons
or have no interest in doing so............................. 6
Because of your vision, how difficult is it for you to go to the movies, theater, or sporting events?
not at all difficult...................................................... 1
a little difficult......................................................... 2
moderately difficult...................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight....................... 5
stopped doing this for other reasons
or have no interest in doing so............................. 6
If you currently drive: how difficult is it for you to drive during the day when driving in familiar places?
not at all difficult....................... 1
a little difficult.......................... 2
moderately difficult........................ 3
extremely difficult.................. 4
How difficult is it for you to drive at night in familiar places?
not at all difficult...................................................... 1
a little difficult.......................................................... 2
quite difficult........................................................ 3
extremely difficult.................................................. 4
stopped doing this due to vision.......................... 5
stopped doing this for other reasons
or have no interest in it............................... 6
16a. How difficult is it for you to drive in difficult conditions, such as bad weather, rush hour, highways, or city traffic?
not at all difficult..................................................... 1
a little difficult........................................................ 2
moderately difficult...................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight........................ 5
stopped doing this for other reasons
or have no interest in doing so............................. 6
Because of your vision, do you accomplish less than you would like?
All of the time.............. 1
Most of the time...................... 2
Some of the time.................... 3
A little of the time...................... 4
None of the time................. 5
Because of your vision, are you limited in how long you can work or perform other activities?
All of the time............. 1
Most of the time..................... 2
Some of the time.................. 3
A little of the time..................... 4
None of the time................. 5
How often do you have to give up things you would like to do because of pain or discomfort in or around your eyes, such as burning, itching, or aching?
All of the time............. 1
Most of the time..................... 2
Some of the time................... 3
A little of the time..................... 4
None of the time.................. 5
Because of my vision, I spend most of my time at home:
definitely true............................. 1
mostly true.............................. 2
don't know............................................... 3
mostly false........................... 4
definitely false.......................... 5
Because of my vision, I often feel annoyed and dissatisfied:
definitely true............................. 1
mostly true.............................. 2
don't know............................................... 3
mostly false........................... 4
definitely false.......................... 5
Because of my vision, I have significantly less control over what I do:
definitely true............................. 1
mostly true............................... 2
don't know................................................ 3
mostly false........................... 4
definitely false.......................... 5
Because of my vision, I have to rely too much on what others tell me:
definitely true............................. 1
mostly true................................2
don't know................................................ 3
mostly false............................ 4
completely untrue........................... 5
Due to vision problems, I often need help from others:
definitely true............................. 1
mostly true............................... 2
don't know................................................ 3
mostly false........................... 4
definitely false.......................... 5
I worry that because of my vision problems, I might do something that would make me or others feel awkward:
definitely true............................. 1
mostly true............................... 2
don't know.................................................3
mostly false............................ 4
completely untrue........................... 5
Interpretation
All questions in the questionnaire are grouped into blocks assessing the patient's physical, mental, and social functioning in relation to their visual quality of life. The total score across all sections of the method allows for assessing the degree of reduction in the patient's quality of life relative to their visual functions.