A 48-year-old woman with high myopia (–12 D) presents with sudden vision loss and a shadow in the inferior visual field for 3 days. Fundoscopy shows an inferior nasal retinal detachment extending from the equator to the posterior pole, with the macula already detached. There is no visible retinal break. B-scan ultrasonography confirms total retinal detachment with no vitreous hemorrhage. What is the most appropriate next step in management?

Explanation

## Clinical Scenario Analysis This is a **macula-off, total retinal detachment with no visible break**—a complex case requiring vitreoretinal surgery with internal tamponade. ### Key Diagnostic Features **High-Yield:** - Macula-off status = poor visual prognosis; urgency is lower than macula-on, but surgery is still indicated. - Total detachment = extensive retinal break(s) likely present but not visible on external examination. - High myopia = predisposing factor; associated with lattice degeneration and multiple breaks. - No visible break on fundoscopy = B-scan was appropriately used to assess media clarity and confirm diagnosis. - No vitreous hemorrhage = media is clear enough for vitrectomy. ### Management Decision Tree ```mermaid flowchart TD A[Macula-off Total RD, No Visible Break]:::outcome --> B{Media Clear?}:::decision B -->|Yes| C[Vitrectomy indicated]:::action B -->|No| D[B-scan to assess VH]:::action C --> E{Single Break or Multiple?}:::decision E -->|Single, Posterior| F[Buckle + Vitrectomy]:::action E -->|Multiple or Anterior| G[Vitrectomy + Internal Tamponade]:::action G --> H[Silicone oil or Gas]:::action D --> I[Clear VH first, then vitrectomy]:::action ``` ### Why Pars Plana Vitrectomy with Internal Tamponade? 1. **Total detachment with no visible break**: Multiple breaks are likely present; vitrectomy allows complete visualization and treatment of all breaks under direct visualization. 2. **Macula-off status**: While the macula is already detached, reattachment is still attempted to preserve any remaining central vision and prevent further degeneration. 3. **Internal tamponade (gas or silicone oil)**: Provides sustained pressure to reattach the retina and seal breaks from the inside. Gas is preferred if the patient can maintain head positioning; silicone oil if breaks are extensive or anterior. 4. **High myopia**: Associated with multiple breaks and higher risk of redetachment; vitrectomy with tamponade offers better long-term control. **Key Point:** - **Macula-off detachments are NOT emergencies** (unlike macula-on). Surgery can be deferred 1–2 weeks without worsening prognosis, but should not be delayed indefinitely. - **Total detachments require vitrectomy**, not buckle alone, because buckle cannot address anterior breaks and multiple breaks cannot be reliably treated without visualization. **Clinical Pearl:** - The **absence of a visible break does not exclude retinal detachment**. In ~10% of cases, breaks are too small or anterior to be seen on indirect ophthalmoscopy. Vitrectomy allows complete inspection under the operating microscope. ### Why Not the Other Options? | Option | Why Incorrect | |--------|---------------| | Bed rest + head positioning | Macula is already off; positioning cannot reattach it. Delays necessary surgery and risks further degeneration. | | Scleral buckle alone | Cannot identify or treat breaks in a total detachment; does not address multiple breaks likely present in high myopia. | | B-scan-guided laser retinopexy | Laser cannot be applied to detached retina; breaks cannot be reliably identified without vitrectomy in total detachment. |