A 58-year-old man from Mumbai presents with sudden onset of floaters and photopsia in his right eye for 2 days. He is highly myopic (−8 D) and has a history of lattice degeneration. On examination, visual acuity is 6/60 in the right eye. Fundoscopy reveals a superior temporal retinal detachment with a single horseshoe tear. The macula is still attached. What is the most appropriate immediate management?

Explanation

## Clinical Scenario Analysis This is a **rhegmatogenous retinal detachment (RRD)** with a single identifiable tear in a highly myopic patient with lattice degeneration—a classic high-risk phenotype. ### Key Diagnostic Features **Key Point:** The presence of a horseshoe tear with superior temporal detachment and intact macula indicates a **macula-on RRD** that requires urgent (not emergent) surgical intervention. **High-Yield:** Myopia is the single strongest risk factor for RRD; lattice degeneration increases tear risk 100-fold. The combination is a surgical emergency. ### Management Algorithm ```mermaid flowchart TD A[Rhegmatogenous RRD diagnosed]:::outcome --> B{Macula status?}:::decision B -->|Macula ON| C[Urgent surgery within 24-48 hrs]:::action B -->|Macula OFF| D[Emergency surgery within 6-12 hrs]:::action C --> E[PPV + gas tamponade ± scleral buckle]:::action D --> E E --> F[Reattachment + visual recovery]:::outcome ``` ### Why Vitrectomy with Gas Tamponade? 1. **Definitive treatment** for RRD with identified tear 2. **Gas bubble** provides internal tamponade, pushing retina back against RPE 3. **Pars plana approach** allows complete vitreous evaluation and removal of vitreous traction 4. **Success rate** >90% for primary RRD with single tear 5. **Macula-on status** allows elective (not emergency) timing but should not be delayed >48 hours **Clinical Pearl:** Scleral buckle alone is insufficient for superior tears with vitreous traction; PPV is now the gold standard for most RRD cases in modern practice. ### Why Not the Other Options? | Option | Why Incorrect | |--------|---------------| | Observation | RRD is progressive; macula-on status will deteriorate to macula-off within days if untreated. Observation is contraindicated. | | Laser photocoagulation alone | Laser can only treat retinal breaks in **rhegmatogenous detachment with NO vitreous traction**. This patient has a horseshoe tear with active traction—laser will fail. | | Anti-VEGF injection | No role in RRD management. Anti-VEGF is for exudative detachment (e.g., diabetic macular edema, AMD). | **Mnemonic: RRD Surgery Timing — MACULA** - **M**acula ON → Urgent (24–48 hrs) - **A**cute presentation → Do not delay - **C**omplete detachment → Emergency (6–12 hrs) - **U**rgency increases with time - **L**aser alone insufficient if traction present - **A**lways use PPV for modern RRD [cite:Parson's Diseases of the Eye 22e Ch 8]