Rhegmatogenous retinal detachment (RRD) is a condition in which a tear forms in the retina, allowing liquefied vitreous to enter the subretinal space and separate the neurosensory retina from the retinal pigment epithelium (RPE) layer. The term “rhegmatogenous” is derived from the Greek word for “tear.”
There are three types of retinal detachment. Rhegmatogenous retinal detachment (RRD) is the most common, distinguished from tractional retinal detachment (TRD: mechanical traction by proliferative membranes) and exudative retinal detachment (ERD: accumulation of exudative fluid from choroidal and retinal vessels). This article focuses on rhegmatogenous retinal detachment.
Exudative retinal detachment does not involve a tear, and shifting fluid that moves with changes in body position is characteristic. Treatment primarily targets the underlying disease, which is fundamentally different from rhegmatogenous retinal detachment.
The concept of repair by closing the tear was established by Jules Gonin in the 1920s. Before that, the cure rate was less than 5%, but Gonin’s ignipuncture (thermocoagulation) improved it to 30–60%. Subsequent developments are as follows:
Currently, the primary success rate exceeds 90%, and with multiple surgeries reaches 98%.
The incidence is 1–1.5 per 10,000 population per year, making it a relatively rare disease. However, in regions or populations with a high prevalence of myopia, the number of cases tends to increase. About 10% of cases occur in both eyes, so regular observation of the fellow eye is important for patients who have undergone surgery in one eye.
Flap Tear (Horseshoe Tear)
A retinal tear caused by vitreous traction. The retinal flap has a horseshoe shape.
Commonly occurs in the superotemporal quadrant (60%) associated with posterior vitreous detachment in middle-aged and elderly individuals. Prone to cause high retinal detachment.
Round Hole with Operculum
Formed when vitreous traction completely detaches the flap of a tear. The detached flap (operculum) floats in the vitreous cavity.
Progression is relatively slow because traction is relieved. However, liquefied vitreous can easily flow in through the enlarged hole.
Atrophic Hole
Caused by atrophic changes in the retina within lattice degeneration. Not accompanied by an operculum.
Common in young people, women, and high myopia. Progression is often slow because vitreous traction is absent.
The predilection site for retinal tears is the peripheral retina, accounting for two-thirds of all cases. By quadrant: superotemporal 60%, inferotemporal 15%, superonasal 15%, inferonasal 10%.
Photopsia is a sign of retinal traction associated with posterior vitreous detachment and can be a precursor to retinal tear formation. Especially if it occurs simultaneously with floaters or is accompanied by visual field defects, same-day consultation is recommended. Retinal tears are found in 5.4–8% of patients presenting with acute PVD symptoms, and in two-thirds of cases with vitreous hemorrhage. 2)
The development of rhegmatogenous retinal detachment requires two absolute conditions: (1) the presence of a hole in the retina, and (2) liquefaction of the vitreous. For a retinal hole to occur, there must be a thinned degenerative area in the retina, or vitreous traction or strong external force applied to the eye.
Retinal tears with the following high-risk features are strong candidates for prophylactic laser photocoagulation.
Risk factors for prophylactic treatment of lattice degeneration: ① history of retinal detachment in the fellow eye, ② aphakic or pseudophakic eye, ③ high myopia with severe lattice degeneration, ④ family history of retinal detachment, ⑤ complications of Marfan syndrome, Stickler syndrome, or Ehlers-Danlos syndrome.
Conditions for laser photocoagulation: gradually increase power from 0.2 seconds, 150 mW, 200 μm to achieve a moderately white coagulation spot. For lattice degeneration, use a three-mirror or wide-angle inverted contact lens to surround the lesion with 2 to 3 rows of coagulation spots without gaps (coagulation size 400–500 μm).
Myopia is the greatest risk factor for RRD, but the incidence rate is 0.01–0.015% of the population, and most people with myopia do not develop it. However, in high myopia (≥ -6 D), the complication rate of lattice degeneration is high, and it is reported that 0.3–0.5% of atrophic holes within lattice degeneration progress to RRD. Regular fundus examinations are particularly important.
Diagnosis involves fundus examination using an indirect ophthalmoscope, a slit-lamp biomicroscope with a pre-corneal lens or a three-mirror lens to identify the detached retina and causative retinal breaks. Slit-lamp examination also allows observation of the vitreous to assess the presence of posterior vitreous detachment and vitreous traction on the break. It is essential to determine whether the detachment extends to the macula, as this affects postoperative visual prognosis.
In outpatient examination, binocular indirect ophthalmoscopy with scleral depression is most useful. Differentiating true breaks from pseudo-holes, evaluating the presence of subretinal fluid around the break, and assessing the extent of detachment are critical for determining the treatment plan.
The following information from the patient history is important for diagnosis and treatment planning: 2)
A practical rule for estimating the location of the causative tear based on the morphology of the detachment.
| Detachment morphology | Predicted tear location | Accuracy rate |
|---|---|---|
| Superior detachment on the temporal or nasal side | Within 1.5 clock hours from the higher border | 98% |
| Superior detachment descending bilaterally beyond 12 o’clock | Within the triangle with apex at 12 o’clock | 93% |
| Inferior retinal detachment | Tear on the higher side of the boundary | 95% |
| Inferior bullous retinal detachment | Originates from a superior tear | — |
倒像鏡による散瞳眼底検査が診断の基本であるが、硝子体出血などで眼底透見が不良な場合はBスキャン超音波が必須となる。また黄斑部の微細な剥離はOCTによる補助が有用である。裂孔の完全な同定のために強膜圧迫法を組み合わせた全周検査が推奨される。
網膜剥離は緊急的な手術治療が原則である。治療の必須条件は裂孔の完全閉塞であり、裂孔が残存すると再剥離を生じる。初回手術で90%以上が、複数回の手術で98%が復位する。
術後視力は術前の黄斑部剥離の有無・剥離期間に大きく左右される。黄斑部が既に剥離している症例では可及的速やかに手術を予定する。適切な時期に手術を行えば95%以上が治癒するが、網膜復位後の視力は約半数が0.5以下であり、視野欠損や歪視症が残ることも多い。
Cochrane系統的レビューおよびメタ解析では、硝子体手術（PPV）と強膜バックリング術（SB）の解剖学的・視力転帰に有意差はなく（低〜極めて低いエビデンス）、術式選択は個々の症例の特性に基づいて判断する。2)
When the macula detaches, irreversible degeneration of photoreceptors begins. In macula-on RRD, 73% achieve corrected visual acuity of 0.5 or better at 2 months postoperatively. In macula-off RRD, about half of patients have visual acuity of 0.5 or less.
Preoperative positioning may suppress fluid flow into the macula:
Surgical technique selection is based on age, presence of posterior vitreous detachment, and location and size of the tear.
This is an external eye surgery in which a silicone buckle is sutured to the sclera on the outside of the eyeball, compressing and indenting the eye wall inward to close the retinal break.
Indications:
Procedure steps:
| Buckle material | Shape | Main use |
|---|---|---|
| Silicone sponge | Localized buckling | Single/localized tear |
| Silicone band | Encircling band | Encircling buckle / 360° buckle |
| Silicone tire | Wide band | Large tears, lattice degeneration |
Outcomes: Initial anatomical reattachment rate over 90%. In phakic eyes, visual outcomes may be superior to vitrectomy, and 5, 6) in macula-off retinal detachment, SB has been reported to show significantly better outcomes. 6)
Major complications: redetachment, PVR, SINS (buckle-induced infection, necrosis, exposure), 4) refractive change (myopic shift), ocular motility disorder/diplopia.
Indications:
Method: After vitrectomy, the tear is sealed, and internal tamponade is performed with gas (20% SF₆, 14% C₃F₈) or silicone oil.
Outcomes: The primary anatomical success rate is comparable to scleral buckling. 2) Cataract acceleration is a disadvantage, and careful consideration is needed in young phakic patients.
Intraoperative macular protection in macula-on cases: Intraoperative macular protection is especially important in cases where the macula is not detached.
Steamroller technique: A procedure to prevent iatrogenic macular detachment by rolling gas over the macula in bullous detachment near the macula. It is known as a unique intraoperative management method for macula-off RRD.
This is an outpatient procedure in which an expansile gas is injected into the vitreous cavity to close the retinal break using the buoyancy of the gas, followed by cryopexy or photocoagulation to create scarring around the break.
Indications:
Types and characteristics of gas:
| Gas | Injection volume | Expansion ratio | Intraocular retention time |
|---|---|---|---|
| SF₆ (sulfur hexafluoride) | 0.5–0.6 mL | Approximately 2 times | Approximately 2 weeks |
| C₃F₈ (perfluoropropane) | 0.3 mL | Approximately 4 times | Approximately 8 weeks |
Procedure flow:
Results of the PIVOT trial (randomized comparison of PR and PPV):
| Outcome measure | Pneumatic retinopexy (PR) group | Pars plana vitrectomy (PPV) group |
|---|---|---|
| Primary reattachment rate | 80.8% | 93.2% |
| Final reattachment rate | 98.7% | 98.6% |
| Postoperative visual acuity (6 months) | 78.4±12.3 letters | 68.5±17.8 letters |
| Cataract surgery (12 months, phakic eye) | 16% | 65% |
The final reattachment rate was nearly equivalent, and the PR group was superior in terms of postoperative visual acuity and less metamorphopsia.
Main complications: Subretinal gas migration (fish-egg phenomenon), 10) new tear formation, central retinal artery occlusion, cataract progression.
This is a segmental scleral buckling procedure without drainage, and is reported to be applicable to approximately 90% of rhegmatogenous retinal detachments. Good outcomes have been reported: primary reattachment rate 91%, after reoperation 97.4%, and PVR incidence 0.9%.
Contraindications are as follows:
| Surgical technique | Main indications | Primary reattachment rate | Characteristics |
|---|---|---|---|
| Scleral buckling | Young age, atrophic hole, simple RRD | Over 90% | Preserves lens, extraocular surgery |
| Vitrectomy | Complex, multiple tears, PVR | Around 90% | Wide applicability, accelerates cataract |
| Pneumatic retinopexy | Superior localized tear | 80.8% | Outpatient, postural restriction, good vision |
| Lincoff-Kreissig method | Approximately 90% of RRD | 91% | Non-drainage, minimally invasive |
The surgical procedure is selected according to the severity of proliferative vitreoretinopathy (PVR).
初回手術で90%以上が解剖学的に復位するが、術後視力は約半数が0.5以下であり、視野欠損や歪視症が残ることも多い。視力予後を決定する最大因子は黄斑部剥離の有無と持続期間である。黄斑剥離前の早期手術では視力予後が良好だが、黄斑剥離後でも早期手術ほど良好な転帰が期待できる。
In phakic eyes with simple RRD (especially in young patients), scleral buckling may result in better visual outcomes. 2, 5, 6) Vitrectomy is chosen for severe PVR or complex RRD with posterior pole breaks. The choice of surgical procedure is determined by a comprehensive assessment of the characteristics and location of the break, severity of PVR, patient background, and surgeon’s expertise.
The conditions for the development of rhegmatogenous retinal detachment are (1) a retinal break and (2) vitreous liquefaction.
Formation of flap tears: Vitreous traction due to posterior vitreous detachment concentrates on lattice degeneration or areas of strong vitreoretinal adhesion. The presence of lattice degeneration or strong vitreoretinal adhesion leads to break formation. It occurs most frequently in the superotemporal quadrant (60%).
Formation of atrophic holes: These form from retinal thinning and necrosis within lattice degeneration without vitreous traction. Common in young individuals, women, and high myopia. Since they occur before posterior vitreous detachment, the vitreous remains attached, and progression is often slow.
When retinal detachment occurs, photoreceptors and retinal pigment epithelial cells are separated, and oxygen and nutrient supply from the choroid is impaired. Early degeneration and loss of photoreceptor outer segments occur, gradually leading to irreversible degeneration.
The main factors for subretinal fluid extending to the macula are as follows.
The mechanism by which the retina is reattached using only scleral buckling without drainage is as follows.
PVR is the most common complication after RRD surgery, defined as tractional retinal detachment due to formation of epiretinal and subretinal proliferative membranes.
Mechanism: retinal detachment → breakdown of blood-retinal barrier → RPE cells, glial cells, and macrophages enter the vitreous cavity → cytokine stimulation (e.g., TGF-β) → epithelial-mesenchymal transition and proliferation of cells → contractile membrane formation → re-detachment.
RPE cells transform into fibroblast-like cells, produce collagen, and form membranous or cord-like proliferative tissue. The old PVR severity classification (Retina Society 1983) is as follows.
The 1991 Machemer new classification considers anterior PVR and subretinal lesions, and describes the extent of lesions using clock hours.
Arndt et al. (2023) reported in a study of 73 non-diabetic RRD and 64 ERD patients that intravitreal glucose concentration in RD eyes (2.28 mmol/L) was significantly higher than in ERM eyes (1.60 mmol/L) (p<0.0001). 1) Intravitreal glucose significantly correlated with macrophage density (p=0.002) and RD extent (r=0.38). It showed an inverse correlation with postoperative macular thickness (MFT) (r=-0.51), and a significant correlation was found between epithelial cell density and PVR-C grade (p=0.002). 1) It has also been hypothesized that collagen cross-linking by advanced glycation end products (AGEs) contributes to vitreous stiffening. 1)
Data from Arndt et al. (2023) suggest that insulin may play a protective role for cones. 1) Based on the hypothesis that the high-glucose environment in RD eyes exacerbates photoreceptor damage, improving visual prognosis through metabolic intervention is a research topic.
German registry data show an increase in annual incidence from 15.6 to 24.8 per 100,000 population, with aging, increasing myopia prevalence, and rising cataract surgery numbers cited as background factors. 2) The risk of RRD after cataract surgery has decreased to 0.21% with improved surgical techniques. 2)
Long-term observation of eyes with a history of untreated ROP found retinal tears in 18.4% of those aged ≤18 years and 35.1% of those aged 19–30 years. 3) The main mechanism is strong vitreoretinal adhesion before posterior vitreous detachment, and the reoperation rate in retinal detachment cases is as high as 36%. Optimizing surgical strategies according to the underlying disease in children and young adults is a challenge. 3)
This technique combines a wide-angle observation system with chandelier lighting to compensate for the limited visibility of conventional procedures. 7) Meta-analyses show that visual acuity and anatomical success rates are comparable to conventional methods, with reduced surgical time. 9)
Postoperative photoreceptor realignment may affect functional outcomes and is being studied as a factor explaining differences in postoperative visual function between scleral buckling and vitrectomy. 6)
For cystoid macular edema (CME) occurring after RRD repair, new treatments such as dexamethasone sustained-release implants are being investigated. 8)
Ahmed Iら（2025）は、RRD修復後にドルーゼンが消失した83歳女性の1例を報告した。11) 機序として網膜下液の溶解および局所炎症応答の関与が示唆されている。
ガス注入による硝子体黄斑牽引（VMT）や黄斑円孔の非手術的解除を目指す研究段階の手技である。
RCOphth iFTMH Guideline（2025年版）では、pneumatic vitreolysisによる黄斑円孔閉鎖率は47.8%、黄斑円孔の新規発生率は5.3%と報告されている。12)
AAO ERM/VMT PPP（2019）が引用するDRCR無作為化比較試験では、C₃F₈による硝子体黄斑牽引解除率が78% vs 9%（偽手術群）であったが、安全性上の懸念により試験は早期中止となっている。13) 現時点では適応が限定的であり、標準治療には至っていない。
Al-Saleh et al. (2025) performed pneumatic retinopexy using SF₆ gas for traumatic macula-sparing RRD, achieving reattachment within 24 hours and a final visual acuity of 20/40. 14) This suggests that with appropriate case selection, this procedure may be effective for traumatic RRD.
Dean et al. (2023) reported a case of worsening inflammation, keratic precipitates, and vitreous opacity occurring 2–3 weeks after vitrectomy combined with scleral buckling. 15) The condition improved with increased steroids and systemic NSAIDs, indicating that HLA-B27 testing is useful in the differential diagnosis of postoperative persistent inflammation.
Au Eong et al. (2024) reported a case of concurrent idiopathic macular hole persisting for 30 years (documented by photographs) and acute macula-on RRD, in which PPV combined with ILM peeling and C₃F₈ tamponade achieved simultaneous reattachment and hole closure. 16) Although visual improvement was limited (remained at 6/45) due to long-term photoreceptor damage, this report is notable for demonstrating the feasibility of simultaneous surgery.
