REVIEW

URRENT
C
OPINION

Risk factors for retinal detachment following

cataract surgery
Sara J. Haug and Robert B. Bhisitkul

Purpose of review
To review and evaluate the current literature on the incidence and risk factors for rhegmatogenous retinal
detachment (RRD) following cataract surgery.
Recent findings
RRD is a serious complication of cataract surgery that can occur in the early or late postoperative periods.
Identifying factors that increase the risk of pseudophakic retinal detachment can aid in management.
Recent studies support long established risk factors for retinal detachment including intraoperative
complications such as posterior capsular rupture (PCR). In addition, the current literature further defines the
risk for pseudophakic retinal detachment associated with younger age at time of surgery, high myopia, and
male sex in several large retrospective studies. Two recent articles also examine the state of the vitreous
before and after cataract surgery and find that patients are more likely to develop posterior vitreous
detachment postoperatively, possibly contributing to the increased risk of RRD.
Summary
Younger age, high myopia, and male sex continue to be associated with higher risk of pseudophakic
retinal detachment. Intraoperative complications such as PCR also increase the retinal detachment risk.
Given the high volume of cataract surgeries performed each year, pseudophakic retinal detachment
contributes significantly to visual morbidity in the United States and Europe.
Keywords
cataract surgery, retinal detachment, risk factors

INTRODUCTION
Cataract surgery is the most commonly performed
procedure in the USA and the United Kingdom and
carries a high expectation for visual improvement
[1,2,3 ]. Rhegmatogenous retinal detachment
(RRD), either in the early or late postoperative
period, is an uncommon but serious complication
associated with cataract surgery and pseudophakia.
The incidence of retinal detachment after cataract
surgery has been estimated to range between 0.6 and
1.7% in the first postoperative year and continues
over time, with an overall incidence of 0.7% [47].
Compared with rates of RRD in the general population of 0.00650.0179% [811], cataract surgery
increases the risk of retinal detachment at least four
fold [6,11].
Cataract surgery continues to evolve, with
increased surgeon experience and wider adoption
of advanced approaches such as topical and intracameral anesthesia, reduced incision size, and
multifocal lens technologies. Recently, several
large-scale studies have clarified the incidence and
&

risk factors of RRD with current cataract surgery. A

recent large retrospective casecontrol study in
Singapore analyzed 24 846 cataract operations performed between 2001 and 2003, with follow-up
through 2008, and found a pseudophakic retinal
detachment rate of 0.16%, lower than rates previously accepted in the literature. Due to the design
of the study, the author included only those cases
that required retinal detachment surgery in the
same hospital as the cataract surgery; therefore,
the rate could be underestimated [12 ]. Another
retrospective study out of Western Australia looked
at 129 982 cataract surgery patients across 46 health
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Department of Ophthalmology, University of California San Francisco,

School of Medicine, San Francisco, California, USA
Correspondence to Robert B. Bhisitkul, MD, PhD, Professor of Clinical
Ophthalmology, UCSF Beckman Vision Center, 10 Koret Way K301,
San Francisco, CA 94143, USA. Tel: +1 415 476 8633; e-mail:
BhisitkulR@vision.ucsf.edu
Curr Opin Ophthalmol 2012, 23:711
DOI:10.1097/ICU.0b013e32834cd653

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Cataract surgery and lens implantation

KEY POINTS

Rhegmatogenous retinal detachment (RRD) is a serious
early or late complication of cataract surgery, occurring
in about 0.7% of all cases, and can account for
significant visual morbidity.

Mean age in the control group was 71.9 years,

whereas mean age in the pseudophakic retinal
detachment group was 63.5 years. In addition, the
odds ratio comparing patients 64 years and younger
to those older than 64 for a poor visual outcome
(vision measured at 6/18 or worse) in eyes with
retinal detachment was 3.1, with a P 0.002 [14 ].
The series from Taiwan found the 8-year RRD rate to
be 6.65% in patients 50 years or younger, 2.57% in
patients between 50 and 60 years, and 2.01% in
patients older than 60 years, further evidence that
younger age remains a significant risk factor for
pseudophakic RRD [13 ]. The time course to retinal
detachment was variable between these two studies.
The study from Moorfields Eye Hospital found
75% of the retinal detachments were identified
within the first two postoperative years, whereas
Sheu et al. [13 ] found that the mean time interval
between cataract surgery to diagnosis of retinal
detachment was 40 months [14 ]. The etiology of
increased risk in younger patients remains speculative. Changes in the vitreous induced by removal of
the crystalline lens are hypothesized to underlie an
increased risk of RRD; therefore, the more structurally formed vitreous in younger patients as well as
the lack of a PVD may contribute to the increased
risk [5]. However, one recent study did not find the
postoperative development of PVD in and of itself to
statistically increase the rate of pseudophakic RRD
[15].
A male predominance in the pseudophakic
retinal detachment group was also noted in the
study from Moorfields [14 ]. In the control group,
38.2% of cataract cases were performed on male
patients, whereas 67.5% of the cases in the pseudophakic RRD group were men [14 ]. Sheu et al. [13 ]
also found male sex to be a risk factor for pseudophakic RRD. The 8-year RRD rate for women in this
study was 1.52% compared with 3.28% for men.
Male sex has long been associated with an increased
risk of RRD, both phakic and pseudophakic, and is
not entirely understood [16]. Sheu et al. [13 ]
hypothesizes an increased and underreported
history of trauma in men versus women, however,
this has not been substantiated with evidence.
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The current literature continues to support known patient

risk factors for pseudophakic retinal detachment,
including younger age, myopia, and male sex.

Intraoperative posterior capsular rupture is also one of
the most significant risk factors for pseudophakic RRD.

&&

facilities in a 21-year period. The overall pseudophakic retinal detachment rate found was 0.7%,
consistent with the previously published values
[3 ]. This study also found the rate of retinal detachment following cataract surgery decreased dramatically over the study time period from 1980 to 2001,
supporting lower rates of pseudophakic retinal
detachment in more recent studies [3 ]. However,
a prospective cohort study in Taiwan followed 9388
consecutive patients undergoing cataract extraction
and intraocular lens implantation from 1999 to
2001 and found a cumulative 8-year retinal detachment rate of 2.31% [13 ].
Certain risk factors such as posterior capsular
rupture (PCR) and other intraoperative complications have long been identified for pseudophakic
retinal detachment. Recent studies confirm these risk
factors and further analyze others such as male sex,
younger age, myopia and the presence of a posterior
vitreous detachment (PVD). This review examines
the current evidence to identify and characterize risk
factors for RRD following cataract surgery.
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PATIENT DEMOGRAPHICS
Demographic factors such as younger age and male
sex have long been known to increase risk of retinal
detachment following cataract surgery, and the
recent literature continues to support these characteristics as risk factors. In the retrospective series
from Singapore, Quek et al. [12 ] found the mean
age of patients who developed pseudophakic retinal
detachment was 55.3 years at the time of initial
cataract surgery compared with an average age of
66.9 years in the entire cohort. When comparing
younger patients to patients more than 70 years of
age, younger patients had significantly higher hazard ratios of retinal detachment (hazard ratio 19.7,
P < 0.05). A second large retrospective casecontrol
series of 63 298 cataracts at Moorfields Eye Hospital
in London also found younger age to be a significant
risk factor for retinal detachment postoperatively.
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www.co-ophthalmology.com

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EYE CHARACTERISTICS
High myopia, defined as axial length greater than or
equal to 26 mm, is also an established risk factor for
pseudophakic retinal detachment. Numerous recent
studies further clarify the risk for pseudophakic RRD
in myopia. The retrospective series by Sheu et al.
[13 ] found an increase in the retinal detachment
rate with increasing axial length. An eye with an
axial length of 2325 mm had an 8-year RRD rate of
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Retinal detachment following cataract surgery Haug and Bhisitkul

2.44% compared with 6.14% in eyes greater than

or equal to 26 mm. These highly myopic eyes had
an adjusted relative risk of 4.19 compared with
eyes with axial length of 23 mm or less. A retrospective study by Jeon et al. [17 ] in Korea looked at
347 eyes with high myopia and found the incidence
of pseudophakic RRD in this group was 1.72%,
compared with a postoperative retinal detachment
rate of 0.28% in the control (hyperopic or emmetropic) group. These rates are somewhat low compared with other published studies, however, mean
follow-up time in this study was only 7.27 months
and the study may not have captured the complete
rates of pseudophakic RRD. A third retrospective
study from Spain looked at 439 highly myopic eyes
with a mean follow-up time of 61.5 months and
found an RRD rate of 2.7% [18]. In addition,
patients were divided into two groups according
to age at the time of surgery. The group with
patients aged 50 years or less had an RRD rate of
3.65% compared with a rate of 2.52% in the group
with patients aged over 50 years. A trend was found,
indicating an association between age at surgery
and increased risk of retinal detachment in high
myopes [18].
Zuberbuhler et al. [19] published a series of
156 eyes with extreme myopia, defined as axial
lengths greater than 30 mm, undergoing phacoemulsification cataract surgery. The eyes in this
study had not had any prior retinal treatments or
surgeries, including prophylactic laser treatments.
The authors determined a retinal detachment rate of
1.3%. This rate is much lower than other studies
looking at highly myopic eyes undergoing cataract
surgery [13 ,17 ,18]. It is again possible that mean
follow-up time (2 years) influenced the lower retinal
detachment rate. Sheu et al. [13 ] found a trend in
their case analysis for a late wave of increased
retinal detachment after 4 years in patients with
axial lengths of more than 26 mm. However,
previous literature shows no evidence of a significant late increase in the lens extraction-related incidence of retinal detachment and considers cases of
retinal detachment occurring after 4 or more years
postoperatively to only be questionably related to
the surgery [2022].
Myopic eyes have a much higher risk of RRD,
whether pseudophakic or phakic. One study
showed a four-fold increase in spontaneous retinal
detachment risk for refractive error of 1.00 to
3.00 D and myopia over 3.00 D was found to
have a 10-fold higher risk of retinal detachment
[23]. None of the current studies compare retinal
detachment rates in age-matched pseudophakic
myopic eyes to phakic myopic eyes, therefore, the
overall increased retinal detachment risk with
&

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cataract surgery has not been established in recent

literature. In 2003, Ripandelli et al. [24] published a
prospective study comparing eyes of 930 patients
with myopia greater than 15.00 D undergoing
cataract surgery in one eye and compared RRD rates
with the phakic, fellow (control) eye over a 3-year
period. Postoperatively, 8% of the operated eyes
had pseudophakic RRD compared with a spontaneous RRD rate of 1.2% for the control eyes,
suggesting an increased risk with cataract surgery.
However, a study by Neuhann et al. [22] looked at
2356 eyes with axial length greater than 27 mm and
found the risk of postoperative retinal detachment
to be 1.52.2%, which was not different than the
incidence of idiopathic retinal detachment in
phakic myopic eyes.
Another characteristic that likely plays a role in
development of retinal breaks and detachments
postoperatively is the presence or absence of PVD
prior to cataract surgery. The relationship between
PVD and RRD is well established. Cataract surgery
induces structural and molecular changes in the
vitreous body due to the loss of stabilization from
the crystalline lens [5,25]. This situation leads to an
increased incidence of PVD following cataract
surgery, which is confirmed by recent studies [26].
A prospective noncomparative case series of 58 eyes
with an absence of PVD on ultrasound preoperatively found that 58.7% of eyes developed a PVD in
the year following phacoemulsification surgery,
with most of the PVDs developing in the first postoperative month [27]. A second study from New
Zealand found that PVD occurs more frequently
in eyes that have undergone phacoemulsification
cataract surgery as compared with age-matched
phakic eyes (50.8% in the surgery group compared
to 20.8% in the control group) [28]. However, PVD
formation in itself was not found to lead to higher
pseudophakic retinal detachment rates in one
recent study unless associated with peripheral lattice
degeneration [15]. Further work remains to be done
to elucidate the interrelationship between younger
age, myopia, and PVD formation as risk factors for
pseudophakic retinal detachment.
A retrospective study in Wenzhou, China found
the cumulative risk of macular hole formation following cataract surgery to be 0.16% in 13 625 eyes
studied, with younger age and absence of PVD being
the most significant risk factor [29]. Similarly, a
small case series of five patients developed acute
vitreomacular traction by postoperative day 1 following routine cataract surgery, which resolved over
time without surgical intervention [30]. These
studies lend further evidence to changes in the
vitreoretinal interface leading to increased risk of
pseudophakic retinal detachment.

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Cataract surgery and lens implantation

INTRAOPERATIVE COMPLICATIONS
PCR has been isolated as one of the most significant
risk factors for pseudophakic retinal detachment. It
is postulated that the anterior movement of the
vitreous as a result of PCR induces dynamic traction
on the vitreous with a consequent retinal tear formation. The study by Quek et al. [12 ] discussed
previously confirmed a significantly higher rate of
PCR in cases that developed retinal detachment
postoperatively than in the entire cohort of cataract
operations performed (23.1 vs. 2%). Average time
for diagnosis of RRD was 15.7 months in this study;
however, in cases with PCR there was a mean interval of only 6.6 months from cataract surgery to
diagnosis of RRD [12 ]. Tuft et al. [14 ] also identify
PCR as a risk factor for pseudophakic RRD. In
patients with RRD, the rate of PCR without vitrectomy was 4% (compared to 1.1% in controls) and
the rate of PCR with vitrectomy was 34.5% in the
pseudophakic retinal detachment group (3.6% in
controls).
An initiative within the Swedish National Cataract Register set up a study group to investigate,
retrospectively, how posterior capsular complications affect risk for subsequent pseudophakic
retinal detachment. They collected a cohort of
23 285 cataract surgeries, of which 2.94% had
capsular complications. From these patients with
capsular complications, a subset was randomly
selected to be in the study group. A control group
was also randomly selected from the cohort. The
3-year incidence of pseudophakic RRD with capsular
complications was 4%, compared with 0.3% in the
control group. The difference in RRD frequency
between the control and study groups was significant, with an odds ratio of 14.8 at a multiple-factor
level. Overall, the authors found more than a
10-fold increase in the risk for RRD after cataract
surgery in patients with a capsule complication
[31].
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CONCLUSION
Retinal detachment is one of the most serious complications following cataract surgery, with overall
rates of about 0.7%, although recent studies indicate
these rates may be declining [3 ,12 ]. Younger age
and male sex continue to be identified as significant
risk factors. High myopia also was found to have
higher rates of pseudophakic retinal detachment in
recent studies compared with emmetropic controls,
although whether these retinal detachment rates are
higher than spontaneous retinal detachment rates
in this population was not determined. The state of
the vitreous preoperatively and postoperatively continues to be an area of research interest. Studies have
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found the incidence of PVD increases after cataract

surgery but the interplay between structural changes
in the vitreous and pseudophakic retinal detachment rates have not yet been elucidated. Cataract
surgery is the most frequently performed surgery in
the USA and the United Kingdom; therefore, even
low complication rates can have a significant public
health impact.
Acknowledgements
None.
Conflicts of interest
R.B.B. is a member of the advisory board for Genentech
Inc., Allergan Inc., and Alimera Sciences Inc. He is a
consultant to Santen Inc. and ActiveSite. The authors
have no financial interests related to the topic of this
manuscript.
There are no conflicts of interest.

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