Mark Packer, MD, shares his perspective on the relationship between ICL implantation or LASIK and retinal detachment.
Given the frequency with which refractive surgery is performed for moderate to high myopia, whether the procedure is phakic refractive lens implantation, LASIK or SMILE, the question of a relationship with retinal detachment often comes up.
Regarding the risk of retinal detachment in the general population, including all types of refractive error, a meta-analysis of complications of myopia published in 2020 indicated that “Annual incidence rates of RD [retinal detachment] ranged from 5.4 per 100,000 persons in Croatia (95% CI, 4.1–6.4), to 16.5 per 100,000 persons in Japan (95% CI, 15.0–18.1).”1 The authors noted that, “Five case-control studies were available for meta-analyses to determine the relationship between myopia and RD in various refractive error categories. All but one study showed a significant higher odds of RD for myopic persons (<0 D) compared with nonmyopic persons.” Of the studies reviewed in this publication, two reported on the US population:
The risk of retinal detachment for patients implanted with MICL lenses as reported in the MICL DFU is 0.19% (1/526) during the first year following implantation compared with the 0.11% annual incidence reported by Burton.4 However, a review of the literature reporting safety outcomes for EVO ICL lenses with the central port design including data from 28 publications of prospective or retrospective case series demonstrated a 0.034% incidence of retinal detachment (1/2,970 eyes) with weighted average follow-up of 16.7 months.5 This rate is actually less than the population-based rate reported by Burton.
Regarding the risk of retinal detachment following LASIK, reported rates have varied from 0.022% to 0.25%.6 These rates are similar to those reported for the moderate to high myopic population, as well as the rates reported following ICL implantation.
Regarding etiology, the risk of retinal detachment in myopia is attributed to anatomic and physiologic characteristics of myopic eyes: “In addition to axial length greater than or equal to 26 mm, the high myopic eye exhibits a thin and fragile sclera, choroidal hemodynamic changes, early and strong vitreous liquefaction followed by earlier posterior vitreous detachment and complex vitreous–retinal interface, pathologic vitreoretinal attachments with higher peripheral retinal break occurrence, irregularity of the posterior border of the vitreous base, and weak retinal adhesion."7
Specifically regarding retinal detachment following posterior chamber phakic IOL implantation, “data suggest that these retinal detachments are part of the natural history of retinal detachment in high-degree myopia."8 Authors have concluded that “we cannot demonstrate that the correction of high myopia by the implantation of phakic lenses plays a role in the eventual occurrence of retinal detachment."9 The American Academy of Ophthalmology Preferred Practice Pattern further states, “Phakic intraocular lenses have not been associated with increased risk of retinal detachment compared with other intraocular interventions in highly myopic patients.”10
In summary, there is no convincing evidence to support a causal relationship between ICL implantation or LASIK and retinal detachment. As noted in the TICL DFU, “The relationship between the Visian TICL and retinal detachment is undetermined.”4 In this light, it remains prudent to inform all myopic patients of their increased risk of retinal detachment, and to counsel them regarding the warning symptoms of flashes and floaters, to facilitate timely treatment and the best possible outcomes.