Retinal Detachment Surgery

The Dilemma Between Personal Experience and Clinical Trials

Peter Walter


Expert Rev Ophthalmol. 2012;7(5):441-447. 

In This Article

Current Debate

What is the ideal procedure to treat rhegmatogenous retinal detachments (RRD)? The question is justified because different techniques are advocated, each characterized by specific success rates, risk profiles and cost–benefit ratios. Surgeons advocating a specific technique are usually presenting success rates with their technique close to 100%. When looking at data from randomized controlled multicenter trials such success rates were not achieved. There are not only differences between surgeons but also differences in several countries as survey data or data from insurances clearly indicate. For example, pneumatic retinopexy (PR) is frequently carried out in the USA but does not play a role in Germany. Moreover, a shift in the popularity of certain techniques can be identified. From MediCare data in the USA it is obvious that scleral buckling (SB) is performed less frequent every year (1997: 38%; 2007: 9%) whereas vitrectomy gained more and more popularity (1997: 45%; 2007: 73%).[1] The same trend is also obvious in other countries: for example, in Taiwan, Ho et al. reported that in 1997, 47.3% of all cases with RRD were managed with vitrectomy whereas in 2005, 61.2% of all these cases were treated with vitrectomy.[2] When individual surgeons are asked what is the ideal technique for the repair of retinal detachment one may receive very different answers. It is generally accepted in medicine that prospective randomized controlled clinical trials provide us with objective data on which method is superior to another. Based on such data, a physician should decide which technique is the best one for the patient. Guidelines published by expert organizations may give information on the best treatment. This approach works very well in internal medicine when two drugs are compared and the more efficient drug is setting the new standard in a certain treatment regimen. In the surgical disciplines, this mechanism does not work with the same automatism and vitreoretinal surgery is not different from other surgical areas. Interestingly, the same dilemma exists in other surgical disciplines. Melis et al. reported that using a questionnaire approach on 110 academia-based digestive surgeons, only 60% of the questions were answered correct according to guidelines and according to published data from randomized multicenter trials,[3] possibly indicating that evidence-based approaches do not necessarily change surgeons minds.

In this article, the author will discuss this obvious difference with respect to the procedures available for the repair of retinal detachments.