How should we report the foveal status in eyes with "macula-off" retinal detachment?

Abstract

Whilst pre- and postoperative multimodal imaging technologies including optical coherence tomography (OCT) have investigated the morphological correlates of worsened visual outcomes in rhegmatogenous retinal detachment (RRD) with foveal involvement, the nomenclature has adhered to the traditional ophthalmoscopy-based and rather vague term "macula-off". This article appraises the current literature with regard to the preoperative assessment and nomenclature of the foveal status in macula involving retinal detachment (MIRD). A literature review of recent publications assessing functional or morphological outcomes in MIRD was conducted, using the search terms "fovea-off" or "macula-off". The search date was April 28^th, 2021. Original studies in English language were included. Case reports, review articles or letters were excluded. Forty relevant articles (range of publication dates: July 29^th, 2020 - April 18^th, 2021) were reviewed to assess the diagnostic modalities used, morphological parameters assessed, and any specific nomenclature introduced to specify the extent of macular detachment. The results suggest widespread variability and inconsistencies with regard to the preoperative assessment, diagnostic modalities and nomenclature used to describe the foveal status in eyes with RRD termed "macula-off". The extent of macular detachment may be classified by a wide range of morphological parameters, including the height of foveal detachment and the ETDRS grid as overlay tool in OCT devices. There is a scientific and clinical need for an updated nomenclature for eyes with "macula-off" RRD. Preoperative OCT findings should be reported on a regular and standardized basis in order to establish a consensus how to report the foveal status in eyes with MIRD.

Fig. 1. Proposal of a five-tier grading system for macula involving retinal detachment.

Visualisation and nomenclature of five grades of Macula Involving Retinal Detachment (MIRD) based on the morphological extent of involvement using an ETDRS-grid overlayed on a 30° Infrared-Image and the corresponding optical coherence tomography scan, adapted from Klaas et al. [4]. Grade 4 (G4) and Grade 5 (G5) are distinguished by a detached foveal centre and are referred to as Center Involving Retinal Detachment (CIRD). In contrast, a center approaching situation (G1-G3) is labelled as Center Approaching Retinal Detachment (CARD).

Fig. 2. Proposal of a six-tier grading system for macula involving retinal detachment.

Visualisation and nomenclature of a six-tier grading system for the detached macula using the ETDRS grid as proposed by Ng et al. [52].

Fig. 3. Example of retinal detachment involving the foveal center and three outer subfields.

Infrared-Image with ETRDS grid overlay in Heyex-2-Software (Heidelberg Engineering, Heidelberg, Germany) and SD-OCT (30°), representing Centre Involving Retinal Detachment with three outer subfield involvement (CIRD G4). Dashed white circles  are added to indicate subretinal fluid within this part of the ring. A continuous white line indicates that subretinal fluid does not cross this boundary. The white and black arrows both mark the margin of detachment in the IR and OCT image, respectively. In at least one outer subfield (∂) no subretinal fluid can be detected in volume or radial scans. * marks one of the four inner (parafoveal) subfields of the ETDRS grid. ƒ marks height of foveal detachment (=291 µm, as measured perpendicularly to the RPE in 1:1 resolution).

Fig. 4. Proposal of a three-tier grading system for macula involving retinal detachment.

Visualisation of a grid-based grading system for eyes with macula involving retinal detachment using the 1.0 mm (red), 3.0 mm (pink) and 6.0 mm (yellow) diameter of the ETDRS grid as proposed by Boden et al. [24]. Grade 3 is further subdivided according to the height of foveal detachment in the corresponding OCT scan (cutoff = 250 µm).