The incidence of rhegmatogenous retinal detachment (RRD) is estimated to be 6 to 18 per 100,000 population,¹ with associated risk factors including myopia, aging, and surgical intervention (eg, cataract surgery). Most RRDs present unilaterally; however, various studies have shown that RRDs can occur sequentially in both eyes in 10% to 20% of patients, depending on population selection and duration of follow-up.² In rare circumstances, a retinal surgeon may face a patient with bilateral simultaneous rhegmatogenous retinal detachments (BSRRD).

BSRRD account for approximately 2% of all retinal detachments.³ There are several retrospective studies^4,5 that describe the clinical characteristics and both structural and functional outcomes of BSRRD.

This rare cohort consists of younger individuals (second to fourth decade) with significant myopia. It is often challenging to determine the approach and timing of surgery in these special cases, but studies show high rates of single-surgery anatomic success. This article presents 2 cases managed at the authors’ institution and discusses a streamlined approach to the surgical management of patients with BSRRD.

CASE PRESENTATIONS

Case 1

A 41-year-old male presented with decreased vision in the left eye. He had a history of high myopia and had undergone clear lens extraction with intraocular lens placement several months prior to presentation. Ophthalmic examination revealed 20/25 Snellen corrected visual acuity (VA) in the right eye and hand motion in the left eye; the posterior segment showed a localized 3 clock hour RRD with a single break nasally in the right eye, and a total RRD in the left eye with multiple breaks superiorly (Figure 1).

After an extensive discussion regarding treatment options, the patient did not want any surgical intervention in the asymptomatic right eye. He agreed to pneumatic retinopexy in the right eye and a combined scleral buckle (SB) with pars plana vitrectomy (PPV) in the symptomatic left eye 2 days later. At postoperative week 1, the retina was attached bilaterally. At postoperative week 3, he had new floaters in the right eye, and was found to have a new but similar localized RRD nasally with a single break just inferior to the previously treated break. After repeat discussion regarding treatment options, he underwent a primary scleral buckle in the right eye and the retina was attached bilaterally at last follow-up, with VA 20/20 in the right eye and 20/40 in the left eye.

Case 2

A 45-year-old female with a history of laser refractive surgery 2 decades earlier presented with decreased vision in the right eye. She reported floaters and a progressive superior curtain in the right eye visual field for 1 week. Ophthalmic examination showed VA of 20/25 in the right eye and 20/20 in the left eye; she was phakic in both eyes, with a RRD in the inferior hemisphere in the right eye and localized inferotemporal RRD in the left eye from a single tear (Figure 2).

The patient was surprised to hear about bilateral pathology. After a discussion of possible treatment options, she underwent laser barricade in the left eye and SB combined with PPV in the right eye. At last follow-up, VA was 20/30 in the right eye and 20/20 in the left eye, and the retina was attached bilaterally.

CURRENT MANAGEMENT OF PATIENTS WITH BSRRD

Treatment Options

Most patients have unilateral symptoms, and most cases appear to have a symptomatic detachment in 1 eye in tandem with a localized asymptomatic RRD in the fellow eye.^4,5 Because most surgeons do not perform same-day bilateral surgery, the surgical management of patients with BSRRD can be variable, particularly if access to the operating room is limited.

Table 1 outlines the general approach used by the authors. In young phakic patients without a posterior vitreous detachment (PVD) and with unilateral symptoms, our preferred approach is a primary SB of the symptomatic eye followed by either a primary SB of the asymptomatic fellow eye or laser barricade if the fellow eye has a small and localized RRD without other areas of pathology.

In cases where the symptomatic eye is macula off, it is at the discretion of the retinal surgeon and patient to decide which eye to operate on first. In such a circumstance, the progression is typically slow, allowing surgeons to address the symptomatic eye before intervening on the asymptomatic fellow eye.

In older phakic patients with a PVD, the surgical interventions become more variable. In the scenario that both maculae are on, the authors prefer a SB without or without PPV in the symptomatic eye. The fellow eye can be treated with various choices, including SB with or without PPV, laser barricade, or, if amenable, possible pneumatic retinopexy (the latter 2 choices would avoid a potential second operating room intervention). If, however, 1 eye has a bullous macula-off RRD, then the macula-on fellow eye should be treated first.

In pseudophakic patients, the authors commonly perform a PPV with or without SB for the symptomatic eye followed by either primary SB or laser barricade of the fellow eye. In cases of a macula-off RRD, the macula-on fellow eye should be prioritized.

A recent study⁵ reviewed all previous published work on BSRRD and found that >80% of eyes underwent primary SB. In line with the experience of the authors of the present article, SB is instrumental in the management of these patients.

Timing

If the decision is surgery in 1 eye and laser barricade for the fellow eye, the authors recommend laser treatment in the office. It may be tempting to perform the laser under sedation in the operating room, but the consequences could be visually serious if surgery is canceled and the patient is subsequently lost to follow-up.

In cases of staggered surgical intervention, the optimal timing of the second surgery is unknown. One report⁵ found no difference in visual or anatomical outcomes if the second staged intervention was performed before 15 days or later than 15 days.

It is visually and functionally incapacitating to have bilateral gas fills or a significant gas fill in 1 eye while freshly recovering from a primary SB in the other eye; thus to limit patient burden, a possibility is to wait until 50% of the gas has been absorbed before attempting the second surgery. In cases that may require bilateral PPV, silicone oil in 1 eye and gas in the other may also be a reasonable approach.

Perceived Difficulties and Patient Expectations

Patients with BSRRD require not only additional discussion regarding the various surgical approaches but also understanding and sensitivity given the potential for bilateral vision loss or blindness. Furthermore, >90% of patients have unilateral symptoms,⁶ so it may be difficult to initially accept and comprehend the need for bilateral intervention. The patient in the first case refused any surgical intervention in his asymptomatic eye until 50% of the gas bubble was absorbed in the surgical eye (when some functional vision was restored).

The typical profile of this cohort are young myopes that may be at the peak of their professional lives and family duties. Bilateral sequential surgery comes with transient bilateral decrease of vision that may significantly undermine the patient’s autonomy.

The retinal surgeon may experience an internal battle between the optimal surgical plan and limiting undue burden, but ultimately should not compromise on best surgical practices in favor of convenience to the patient. It is important to have a frank discussion about the surgical management and postoperative care (both first and second surgery) with the patient in order to come to a mutual and favorable decision. Although the authors outline their approach above, there is significant room for modulation of treatment options based on surgeon preference, extent of pathology, and patient circumstances.

Retinal detachments are vastly heterogeneous, necessitating the retinal surgeon to employ various tools and strategies for successful reattachment of the retina. Although BSRRD are rare, they present a unique challenge that requires a thoughtful and tailored approach to each case. RP

REFERENCES

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2. Folk JC, Burton TC. Bilateral phakic retinal detachment. Ophthalmology. 1982;89(7):815-820. doi:10.1016/s0161-6420(82)34717-x
3. Krohn J, Seland JH. Simultaneous, bilateral rhegmatogenous retinal detachment. Acta Ophthalmol Scand. 2000;78(3):354-358. doi:10.1034/j.1600-0420.2000.078003354.x
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5. Singh N, Jain M, Jaisankar D, Sharma T, Raman R. Bilateral simultaneous rhegmatogenous retinal detachment: clinical characteristics and surgical outcome. Retina Phila Pa. 2019;39(8):1504-1509. doi:10.1097/IAE.0000000000002208
6. El Matri L, Mghaieth F, Chaker N, Kamoun M, Charfi O, Chaabouni A. [Simultaneous bilateral rhegmatogenous retinal detachment. 7 case studies]. J Fr Ophtalmol. 2004;27(1):15-18. doi:10.1016/s0181-5512(04)96086-x