This study was approved by the Institutional Review Board of Ajou University Hospital (No. AJIRB-MED-MDB-21-667) and complied with the Declaration of Helsinki. We retrospectively reviewed the medical records of AD patients who underwent PPV for RD at the Ophthalmology Department of Ajou University Hospital between January 2016 and December 2021. The requirement for informed consent was waived due to the retrospective nature of the study. The exclusion criteria were as follows: (1) patients with a history of previous retinal surgery (scleral bucking or PPV), (2) those who developed rhegmatogenous RD due to trauma, and (3) those who were followed up for less than 3 months after retinal surgery.

One of the two retinal specialists performed PPV for RD repair. PPV with or without cataract surgery was performed using the Constellation 25G System (Alcon Laboratories). Tamponade was performed with silicone oil (Oxane 5700, Bausch & Lomb Inc) or 10% to 12% C₃F₈ gas (Teknomek) at the end of the PPV. The combined surgical method was determined by each surgeon according to age, lens status, location of retinal break, extent of detached retina, and presence of proliferative vitreoretinopathy (PVR). If the cataract grade was high enough to interfere with fundus visualization before and during PPV, cataract removal and intraocular lens implantation were combined. Scleral bucking or encircling was performed using a silicone sponge or tire fixed with 5-0 Dacron sutures.

Demographic factors, such as age, sex, and ocular findings, including best-corrected visual acuity (BCVA) before and after surgery, were obtained from medical records. Successful primary RD repair was defined as reattachment of the retina maintained for more than 3 months after surgery. The presence of PVR was identified on the basis of the Retina Society classification. BCVA was measured using the Snellen visual acuity chart and converted to logarithm of the minimum angle of resolution (logMAR) for statistical analyses. Axial length was measured postoperatively in macula-off eyes with RD. Categorical variables are presented as numbers (percentages), whereas numeric variables are presented as mean ± standard deviation. The paired t-test was used to analyze the change in BCVA following surgery, and values of p < 0.05 were considered statistically significant.

A total of 17 patients with AD who underwent RD surgery were identified, and one patient was excluded because no definite retinal break was found as the cause of RD. Two patients, both in their twenties, have received scleral bucking for primary RD repair due to clear crystalline lens and small single retinal break at far periphery. A total of 20 eyes with RD of 14 AD patients that received PPV were finally included for this analysis, including six patients with bilateral rhegmatogenous RD. The mean follow-up period was 28.6 ± 17.4 months (range, 4-60 months).

Demographic and preoperative ocular characteristics are summarized in Table 1. Mean age was 27.1 ± 10.5 years (range, 17-50 years), and there were 12 male (85.7%) and two female patients (14.3%). The mean axial length of the included eyes was 25.8 ± 1.6 mm. Among the 20 eyes, eight (40%) were pseudophakic, and RD was noted within 2 months of cataract surgery in five eyes. Nearly half (45%) of the rhegmatogenous RD cases involved the macula, with 5.9 ± 2.9 clock hours (range, 2-12 clock hours) as the mean extent of detachment. PVR was found in 30% (6 of 20 eyes), presenting grade C in all cases: three eyes with grade C posterior PVR and three eyes with grade C anterior PVR. Retinal breaks were found mainly at the temporal (nine eyes at temporal and eight eyes at superotemporal, 85%), with mean number of 1.4 ± 0.9 (range, 1-4). Giant retinal tears were observed in 10% of patients.

PPV was performed in 20 eyes, and combined vitrectomy with cataract surgery was performed in eight eyes (Table 2). Scleral bucking or encircling was combined with PPV in four eyes; this was done to release vitreoretinal traction and to provide retinal support in cases with diffuse vitreoretinal pathological conditions such as giant tears and extensive peripheral degeneration, and in cases with PVR of grade C. Retinal reattachment was achieved with the initial surgery in 17 eyes (85%), especially in 15 of 16 eyes (93.8%) that underwent PPV with or without cataract surgery. BCVA (logMAR) was significantly improved at final examination, changing from 0.89 ± 0.72 to 0.23 ± 0.46 (p = 0.001).

Oral corticosteroids were prescribed postoperatively in most cases (95%), with patient case already taking oral prednisolone for AD treatment. Prednisolone starting from 20 to 30 mg or triamcinolone from 16 to 24 mg and then tapered was usually prescribed for 1 to 8 weeks. Cyclosporine and/or antihistamine agents were used in 60% of patients whose information regarding AD medication was available.

There is no significant difference between scleral buckling and PPV in the primary success rate, final visual acuity, and final anatomical success in the treatment of rhegmatogenous RD [14]. RD in patients with AD often involves both eyes and occurs in younger patients, compared to other RD patients without AD [10,13]. The rate of retinal reattachment after primary surgery in AD patients was 72% to 75% in studies before the 2000s, which was lower than the success rate of rhegmatogenous RD in patients without AD [15,16]. A case series with bilateral RD in AD patients revealed poor visual prognosis despite PPV combined with scleral bucking performed in most cases [12]. Accordingly, it is not easy to select an appropriate surgical method because of the relatively poor prognosis of RD in patients with AD.

It has been reported that causative breaks are often located at the periphery, especially in the temporal quadrant, and that retinal dialysis is relatively common in AD patients [13,17-19]. In this study, most peripheral retinal breaks were identified in the temporal quadrant, including retinal dialysis, which is similar to previous studies [17,18]. As peripherally located retinal breaks are easy to approach externally, scleral buckling or encircling might be primarily considered to treat RD in younger AD patients. Accordingly, scleral buckling or encircling, which are appropriate methods to treat RD with peripheral break in young patients with phakic eyes, has been frequently performed in AD patients either combined with PPV or alone.

In this study, PPV either alone or in combination with cataract surgery was mainly applied as primary treatment as three-quarters of the included cases had already undergone or needed cataract surgery in this study. The surgical result of a 94% success rate in these cases suggests that PPV, either alone or combined with cataract surgery, might be sufficient to treat RD in patients with AD. Although this was a retrospective investigation with a small number of cases, the reattachment rate of PPV without additional scleral buckling in AD patients is not inferior to the surgical results in patients without AD [13,20]. On the other hand, PPV combined with encircling had been performed frequently in AD patients presenting large extent of detachment, concomitant PVR of grade C, and/or pseudophakia in this retrospective analysis. It should be noted that reoperation was needed in half of these eyes received PPV with encircling, with new retinal breaks. Moreover, eyes that required reoperation were all pseudophakic, which could mean that AD complications were severe enough to perform cataract surgery at a young age, and this might have been related to RD severity leading to severe tractional force in PVR and/or nearly total detachment. There is also another possibility that the existing tear might have been missed due to difficulty in observing the periphery in pseudophakic patients. Additional encircling or buckling might be helpful in these cases.

It is reported that the surgical results did not show differences between PPV with PPV combined with scleral bucking in noncomplex rhegmatogenous RD, which was probably related to the technological improvement of PPV [20]. Combined scleral buckling with PPV did not provide additional benefits in success rate or visual acuity even in patients with pseudophakia and inferior or multiple breaks [20,21]. The surgical trend for rhegmatogenous RD is significantly shifting from scleral buckling to PPV [22]. Due to the advancement of equipment, especially microincision vitrectomy surgery, PPV has been evolved remarkably, thus reducing operation time [23]. PPV also has fewer complications, such as diplopia and unpredictable refractory changes, than scleral buckling. Although PPV is more likely to induce cataracts, patients with AD often present with significant cataracts [6]. Cataract surgery can be performed simultaneously with PPV, and detailed examination and treatment are allowed in PPV for multiple peripheral retinal breaks even close to the ciliary epithelium. Taken together, we suggest that this trend toward the use of PPV might also be applicable in the treatment of rhegmatogenous RD in patients with AD. However, it should be noted that the decision for proper treatment depends largely on the individual characteristics of each patient, such as the presence of PVR whether additional encircling or buckling should still be applied.

On the other hand, AD has been better controlled than before with the introduction of new treatments such as topical calcineurin inhibitor tacrolimus, and the use of rhegmatogenous RD in AD patients has declined since the 2000s [10]. As inflammation is well controlled, the postoperative inflammatory response might also be greatly reduced. This could be another reason for the higher success rate of surgery in this study, which included cases operated on within the last 5 years. It should be also noted that cases that needed reoperation were all pseudophakic in their 20s, suggesting severe AD complications. AD itself is a risk factor of rhegmatogenous RD in children [24], so that early and sufficient control of AD might be helpful for visual prognosis.

This study has several limitations related to its retrospective nature, the small number of patients included, and the lack of a control group. The surgical methods had been determined by each surgeon, so that the conclusions of this study were based on retrospective data analysis. Further prospective studies may provide further evidence for treatment guidelines for RD surgery in patients with AD.

The most important factors in determining RD surgery are preoperative clinical features, such as the presence of PVR, location of the retinal break, and extent of RD. The results of this study support that favorable surgical results can be obtained with PPV for RD even in patients with AD, if cases are properly selected.