1. Introduction
Retinal detachment is defined as the separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE). In its rhegmatogenous form, liquefied vitreous detaches the retina by passing through a retinal tear or hole. Its incidence is around 1 in 10,000 persons per year [
1]. According to the macular involvement, it may be classified as “macula on” or “macula off” retinal detachment. Especially when it is of recent onset and without macular involvement, it is considered a surgical emergency. Potential risks of delayed surgery are a progression of the detached retina, development of proliferative vitreoretinopathy, and worse functional outcomes if the macula becomes involved [
2]. It may lead to blindness of the affected eye unless surgical treatment is promptly performed. There is no ideal strategy for its treatment. The currently available options are scleral buckling, pars plana vitrectomy, and pneumatic retinopexy. Each one has characteristic advantages for certain patients. After vitrectomy, a tamponade with gas or silicone oil is required [
3]. In some cases, visual results may be unsatisfying. In order to better understand factors affecting postoperative prognosis, several studies have been conducted correlating optical coherence tomography (OCT) findings with clinical outcomes [
4]. Spectral-domain OCT (SD-OCT) and swept-source OCT (SS-OCT) are both types of Fourier domain OCT. Nowadays, they have a high sensitivity, providing high imaging speed, improved image contrast, full volumetric tissue information, and high resolution in the three dimensions [
5]. OCT usually refers to B-scan imaging, derived from sagittal and transverse sections. C-scan, or en face OCT, is an application of SD-OCT, producing frontal sections of retinal layers [
6]. Three-dimensional images are obtained with serial horizontal or vertical B-scan images, which are reconstructed in a three-dimensional “cube” [
7]. OCT angiography (OCT-A) is a novel development, allowing visualization of the retinal vascularization without a contrast agent [
5]. Recently, instruments using adaptive optics have been combined with SS-OCT imaging (AO-OCT). Adaptive optics produce a two-dimensional areal image of the retina with a cellular resolution. Therefore, this multimodal retina imaging system may add cellular resolution to images obtained with SS-OCT [
8].
This review aims to be an update of the knowledge on the subject so far, taking into account SD-OCT, SS-OCT, OCT-A, three-dimensional OCT (3D-OCT), and AO-OCT.
Although some authors have performed OCT studies specifically focused on the postoperative period in order to study surgical complications, such as macular hole formation, these findings will be only briefly touched on the present review [
9,
10].
4. Discussion
Rhegmatogenous retinal detachment is a potential cause of permanent vision loss. Its treatment requires surgical intervention, which aims to reattach the retina closing the breaks and releasing vitreoretinal tractions. Pneumatic retinopexy, scleral buckling, and vitrectomy are efficacious techniques with high success rates [
56,
57,
58,
59]. However, anatomical and functional postoperative success is affected by several factors.
OCT imaging enables the detection of structural changes which are not always evident in clinical examination. Therefore, several studies have been performed in order to obtain a better understanding of rhegmatogenous retinal detachment, and to identify possible biomarkers which may influence the prognosis [
60,
61].
In the literature, there are limited data on the subject. Most importantly, the majority of studies are retrospective in nature and only a few RCTs are available. Currently, a meta-analysis on the subject cannot be performed. The present narrative review sums up the different and sometimes conflicting evidence from the available studies to date. More research is needed in order to define the best practice pattern for the management of retinal detachment and its prognosis.
Actual knowledge on the physiology of retinal reattachment has improved thanks to studies using SS-OCT. This enhances the understanding of certain anatomic abnormalities occurring after retinal reattachments, such as outer retinal folds, outer retinal corrugations, and residual subfoveal fluid blebs [
31].
Studies on OCT are not only useful to find new predictors of visual prognoses but also to improve the classification of rhegmatogenous retinal detachment. Traditionally, rhegmatogenous retinal detachment is classified according to the presence/absence of proliferative vitreoretinopathy and the status of the macula (macula-on/macula-off). In some cases of foveal-splitting retinal detachment diagnosed with clinical examination, SD-OCT allows the identification of a complete macular detachment, which was, however, associated with a better visual prognosis than a macula-off detachment. It may be useful to classify these cases as macula-on/off retinal detachment, in order to better stratify the visual prognosis [
29].
Among the potential biomarkers predicting functional recovery, the grade of detachment and the extent of cystoid macular edema seems promising in eyes with a detached fovea, as well as the integrity of the ellipsoid zone [
14,
30]. The extent of the detachment, the postoperative foveal contour, the integrity of the ellipsoid zone and of the external limiting membrane, and the presence of outer retinal folds, seem to be predictors of visual prognoses and metamorphopsia following a successful vitrectomy [
12,
15,
16,
17,
22,
28,
48,
49]. In addition, the thickness of the inner and outer segments of the photoreceptors, and thickness changes in the outer nuclear layer, may be predictors of the final visual outcome [
19,
21]. Lower preoperative central retinal thickness is associated with a good visual prognosis [
12,
20]. Irregularity in the reflectivity of the ellipsoid zone may be associated with outer retinal folds. These alterations may represent subtle damage to the photoreceptors [
22]. Outer retinal undulation may have a role in assessing the duration of retinal detachment, but it does not seem to be related to the visual prognosis [
14]. Recovery of the integrity of the ellipsoid zone may be associated with postoperative improvement in visual acuity [
18]. Persistent subfoveal fluid resolves spontaneously in the majority of cases, but it may also be rarely associated with progressive foveal photoreceptor atrophy and loss of visual acuity. It occurs more frequently when the macula-off retinal detachment is secondary to atrophic round holes or dialysis [
41]. The quantity of macular subretinal fluid may also be considered a biomarker since it is correlated with low visual acuity and cavitations of the external nuclear layer [
13]. On the other hand, other studies failed to find a significant correlation between the height of the retinal detachment and the visual outcome. The preoperative presence of a macular hole, instead, significantly affects postoperative visual acuity [
27]. Intraretinal cystoid cavities do not seem to impair postoperative anatomical and functional outcomes [
25].
OCT-A studies may also help to identify biomarkers useful for predicting functional and anatomical visual prognoses. OCT-A findings have suggested a potential relationship between outer retinal restoration, the VD of the choriocapillaris, and visual prognosis in macula-off retinal detachment after a vitrectomy [
43]. In these patients, an enlargement of the FAZ with reduced VD of the superficial and deep capillary plexuses have been observed, together with inner retinal layer thinning [
44]. The enlarged area of the deep FAZ continues to increase in eyes with retinal detachment and choroidal detachment, suggesting that choroidal lesions may have an acute pathological effect on ischemia of the deep retinal capillary network. Therefore, early intervention on retinal and choroidal ischemia may improve the structural recovery of the retina and the visual prognosis. Moreover, the extent of the deep FAZ may be used to predict postoperative visual acuity [
45]. On the other hand, some authors have also found no correlation between FAZ, VD, and visual prognosis. The finding that eyes treated with vitrectomy have a lower VD than eyes treated with scleral buckling suggests that vitrectomy may potentially damage the microvascular structure of the vessels [
46]. However, further studies are needed.
The timing of intervention for the treatment of retinal detachment is also a debated issue. High-risk indicators may facilitate the identification of eyes that benefit more than others from urgent surgery [
62]. The evidence that a disrupted intraretinal appearance of the detached macula may be associated with a worse visual prognosis may aid in the selection of patients who may potentially benefit from early surgery [
23]. The integrity of the photoreceptor layer seems to improve postoperatively over time. A longer time period before surgery is associated with a worse status of the photoreceptors, and it is subsequently associated with a worse visual outcome. This highlights the importance of early intervention, even in macula-off retinal detachment [
24].
Studies on AO-OCT, though conducted on small samples, have highlighted that retinal reattachment after surgery does not correspond to a restoration of the outer segments of the photoreceptors, which remain considerably misaligned even after a quite long follow-up time. Structural damage to the photoreceptors prevents normal coupling of light, causing distorted and attenuated signals [
4].
Postoperative photoreceptor integrity may represent a predictor of better postoperative functional outcomes. Discontinuity of the outer retinal layers and development of outer retinal folds, which are also associated with vertical metamorphopsia if close to the fovea, seem to be associated with worse visual outcomes. The surgical technique used to treat the retinal detachment may play a role in the genesis of these alterations, as suggested by some recently published studies [
38,
39]. However, no large RCTs are available and there is still limited data on the topic, insufficient to suggest a preferred surgical strategy. Further research on the subject should be encouraged in order to identify those OCT findings that may be relevant and crucial for choosing the most appropriate surgical technique.
It has been suggested that an abnormal macular status in the postoperative period may lead to a poor visual outcome [
40]. Morphological OCT changes in the macular region seem to affect both macula-on and macula-off detachments [
42]. Further studies are needed in order to clarify the role of ILM peeling, especially regarding the formation of epiretinal membranes and proliferative vitreoretinopathy in the postoperative period [
51]. At the same time, studies performed with en face OCT for the detection of postoperative epiretinal membranes concluded that they are usually not severe and they have only a marginal impact on postoperative visual acuity [
50].
OCT findings are useful to choose among the different endotamponades available since it is known that silicone oil, but not gases, is associated with retinal thinning. The inner retinal layers are affected: mainly the ganglion cell layer and the inner plexiform layer. Their thickness may be a predictive factor to assess the final visual acuity [
34]. The parafoveal inner retinal thickness may return to normal after silicone oil removal, while the peripapillary nerve fiber layer thinning remains constant. A mechanical effect caused by the pressure of silicone oil on the retina, especially in the prone position, may be assumed [
35]. The mechanism of action and the effects on visual outcome are still unclear, therefore it may be advisable to use silicone oil only in complicated cases. Moreover, monitoring of retinal thinning using SD-OCT may support the decision to remove silicone oil with the correct timing in order to minimize the potential thinning effect on the retina [
32,
33]. Extended use of heavy silicone oil is associated with an increased risk of ERM formation [
36]. It is likely that the retina is more susceptible to damage from silicone oil than the choroid since silicone oil makes contact only with the retina. OCT-A may show a reduced VD of the superficial capillary plexus only, although no alterations of FAZ and VD may be observed [
35,
46].