Novel classification system for management of rhegmatogenous retinal detachment with minimally invasive detachment surgery: a network meta-analysis of randomized trials focused on patient-centred outcomes

Objective To describe a novel classification system for primary rhegmatogenous retinal detachment (RRD) based on level 1 evidence assessing the functional outcomes of repair techniques with the goal of using a minimally invasive detachment surgery. Methods A systematic review and network meta-analysis of randomized, controlled trials comparing pneumatic retinopexy (PnR), scleral buckle (SB), or pars plana vitrectomy (PPV) for RRD was conducted. Primary outcomes were best-corrected visual acuity (BCVA), metamorphopsia, and operative complications. A meta-analysis was performed with a random effects maximum likelihood model, with outcomes of standardized mean difference (SMD) or risk ratio (RR) and 95% confidence interval. Inclusion and exclusion criteria were assessed to inform a classification system. Results Fourteen trials were included. RRDs were classified from categories 1–3 based on configuration (simple to complex). There was no significant difference in final BCVA between PnR and PPV (categories 1 and 2; SMD = –0.10, 95% CI –0.24 to 0.04), nor was a final BVCA difference found between SB and PPV (SMD = 0.01, 95% CI –0.05 to 0.08), combined SB + PPV and PPV (SMD = 0.02, 95% CI –0.08 to 0.12), or combined SB + PPV and SB (SMD = 0.01, 95% CI –0.11 to 0.12). SB had an elevated risk of choroidal detachment (RR = 5.17, 95% CI 1.68–15.97), hypotony (RR = 12.26, 95% CI 1.63–92.04), and strabismus or diplopia (RR = 5.86, 95% CI 1.04–32.91) compared with PPV but a lower risk of iatrogenic breaks (RR = 0.08, 95% CI 0.02–0.43). Vertical metamorphopsia scores were superior for PnR over PPV at 12 months (Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial, p = 0.026). Conclusion This novel classification system may be useful for future trials assessing morphologic categories of RRD in a systematic manner. Minimally invasive detachment surgery may allow for trials to focus on maximizing functional outcomes while minimizing morbidity.