OCT biomarkers of rhegmatogenous retinal detachment: prognostic value for anatomical and functional surgical outcomes

Dilara B. Babaeva; Бабаева Дилара Байрамовна; Rinat R. Fayzrakhmanov; Файзрахманов Ринат Рустамович; Evgeniya A. Larina; Ларина Евгения Артемовна; Alexandr A. Daloglanyan; Далогланян Александр Ашотович; Darya A. Romanova; Романова Дарья Александровна; Alim A. Zhaboev; Жабоев Алим Аслангериевич

doi:10.17816/clinpract692182

OCT biomarkers of rhegmatogenous retinal detachment: prognostic value for anatomical and functional surgical outcomes

Authors: Babaeva D.B.¹, Fayzrakhmanov R.R.¹, Larina E.A.¹, Daloglanyan A.A.¹, Romanova D.A.¹, Zhaboev A.A.¹
Affiliations:
1. National Medical and Surgical Center named after N.I. Pirogov
Issue: Vol 17, No 2 (2026)
Pages: 139-147
Section: Reviews
Submitted: 07.10.2025
Accepted: 12.12.2025
Published: 18.03.2026
URL: https://clinpractice.ru/clinpractice/article/view/692182
DOI: https://doi.org/10.17816/clinpract692182
EDN: https://elibrary.ru/BZPDVE
ID: 692182

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Abstract

Rhegmatogenous retinal detachment is one of the leading causes of vision loss among the working-age population. Recent advances in ophthalmology include surgical techniques such as vitrectomy, scleral buckling, pneumatic retinopexy, intraoperative retinal photocoagulation, and retinal cryopexy, as well as their combinations. They have led to significant progress in the treatment of this condition; however, the desired anatomical and functional outcomes of surgical intervention are still unattainable in a number of cases. Characteristics of retinal detachment such as proliferative vitreoretinopathy, the extent of rhegmatogenous retinal detachment, the number and location of retinal breaks, structural changes, and macular involvement are being actively studied as factors determining the disease severity. To date, no standardized algorithms or objective criteria for preoperative assessment have been introduced into clinical practice to guide the choice of surgical treatment for rhegmatogenous retinal detachment. At the same time, a considerable number of studies have been devoted to the evaluation of various morphological changes in rhegmatogenous retinal detachment using optical coherence tomography (OCT). OCT focuses on the condition of the ellipsoid zone and external limiting membrane, outer retinal corrugations, intraretinal cystic cavities, macular thickness, and the length of the outer photoreceptor segments. These parameters are potential biomarkers of functional recovery after surgery. Systematization and analysis of research findings related to potential OCT biomarkers in retinal detachment may contribute to the development of new diagnostic approaches and surgical treatment strategies.

Keywords

rhegmatogenous retinal detachment, optical coherence tomography, biomarkers, review, ellipsoid zone, external limiting membrane, photoreceptors, surgical outcome prediction

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BACKGROUND

Rhegmatogenous retinal detachment (RRD) is one of the most serious ophthalmic emergencies requiring timely surgical treatment to prevent complete and irreversible vision loss [1]. The incidence of RRD in different countries averages 12.17 cases per 100,000 population per year [2]; however, a significant increase in this rate has been observed [3], largely due to the growing proportion of elderly individuals as well as the increasing prevalence of myopia.

RRD is secondary to a full-thickness retinal break, causing the vitreous to enter the subretinal space and leading to the separation of the neurosensory retina from the underlying retinal pigment epithelium [4].Current treatment strategies for RRD include surgical techniques such as vitrectomy, scleral buckling, pneumatic retinopexy, intraoperative retinal photocoagulation, and retinal cryopexy, as well as their combinations [5]. Despite the considerable success rate of these treatment approaches, in a number of clinical cases it is not possible to achieve favorable anatomical and functional surgical outcomes [6].

Baseline visual acuity, proliferative vitreoretinopathy, the extent of retinal detachment, and macular involvement are key factors considered during preoperative planning and have a significant impact on postoperative treatment outcomes [7]. The classification of proliferative vitreoretinopathy proposed by Machemer et al. in 1991 [8] has gained wide clinical acceptance and remains relevant today. However, its important limitation is that it does not account for intraretinal structural changes and therefore does not allow a comprehensive assessment of pathological process activity [9, 10]. Meanwhile, optical coherence tomography (OCT) has been well-established as a universal and highly accurate tool for the diagnosis and evaluation of retinal status, providing detailed visualization of retinal structures [11]. Over the past decade, structural retinal changes in RRD detected by OCT have been actively investigated. The most commonly reported findings include disruption of the external limiting membrane and the ellipsoid zone, the presence of an epiretinal membrane, cystoid macular edema, persistent subretinal fluid, and alterations in central foveal thickness [12–14]. According to several studies, these pathological features are potential prognostic biomarkers in RRD, opening new perspectives for assessing disease severity and treatment effectiveness in retinal detachment [15–17].

ELLIPSOID ZONE AND EXTERNAL LIMITING MEMBRANE

The retinal ellipsoid zone appears on OCT as a homogeneous outer hyperreflective line located immediately beneath the external limiting membrane. It corresponds to the outer portion of the photoreceptor inner segments and is considered an established structural biomarker of photoreceptor integrity [18]. Key characteristics of the ellipsoid zone evaluated by OCT, such as its integrity, the extent of damage, and the degree of reflectivity may serve as indicators for monitoring disease progression or therapeutic response in retinal disorders [19] (Fig. 1).

Fig. 1. Spectral-domain optical coherence tomography in rhegmatogenous retinal detachment before and after vitrectomy (images from the authors’ collection): long outer segments of photoreceptors are visualized in a patient with recent rhegmatogenous retinal detachment (6 days); however, a defect of the ellipsoid zone in the foveolar area is detected; BCVA=0.1 (a). Optical coherence tomography performed 3 months after surgery demonstrates persistence of the ellipsoid zone defect; BCVA=0.7 (b). BCVA: best corrected visual acuity.

In one of the early studies, Kang et al. [12] reported that the only preoperative predictor of final visual acuity assessed by spectral-domain OCT in patients with macula-off RRD was the preservation of hyperreflective outer retinal bands of the neurosensory retina. However, the limitations of this study include a small sample size and its retrospective design. In a larger retrospective study, Karacorlu et al. [20] demonstrated an association between preoperative defects in the external limiting membrane and ellipsoid zone and postoperative visual acuity during more than 6 months of follow-up. It should be noted that the study population included patients with recent RRD (<10 days), so the study findings suggested that alterations of the external limiting membrane were a more reliable marker. Similarly, Klaas et al. [21] reported that the preservation of the external limiting membrane and ellipsoid zone prior to surgery remains one of the most reliable predictors of functional recovery after surgical treatment of macula-off RRD. In contrast, pronounced retinal thickening, absence of the foveal depression, and the presence of hyperreflective dots were associated with unfavorable outcomes.

However, in contrast to these findings, several studies have reported that reliable evaluation of the external limiting membrane and ellipsoid zone in cases involving the macula is often difficult [16, 22]. This limitation introduces selection bias and restricts the practical applicability of ellipsoid zone parameters as universal preoperative biomarkers.

A number of studies have also focused on postoperative evaluation of the external limiting membrane and ellipsoid zone. According to Hänsli et al. [23], preservation of the ellipsoid zone and integrity of the external limiting membrane in the postoperative period correlated with improvement in visual acuity during 6 months of follow-up. In this study, most patients underwent internal limiting membrane peeling, while the number of patients with preserved internal limiting membrane was too small to allow meaningful comparative analysis of different surgical techniques.

A post hoc analysis based on the PIVOT randomized clinical trial compared the status of the external limiting membrane and ellipsoid zone 12 months after surgical treatment using vitrectomy and pneumatic retinopexy [24]. The results of this analysis indicate that patients with recent RRD without giant retinal tears and with ≤C1 proliferative vitreoretinopathy, both macula-off and macula-on, demonstrated better preservation of the external limiting membrane and ellipsoid zone after pneumatic retinopexy.

In a randomized pilot study, Peiretti et al. [25] evaluated the use of perfluorocarbon compounds and differences in postoperative patient positioning as possible factors influencing the integrity of the retinal ellipsoid zone. The study included a relatively small patient cohort (n=56) and focused on cases of recent RRD (≤10 days) with macular involvement and the presence of both outer and inner retinal folds. However, no data were provided regarding baseline visual acuity or the presence of proliferative vitreoretinopathy. According to the study results, these factors had no effect on disruption of the ellipsoid zone, although the findings require confirmation in larger studies.

Unlike previous studies, Sassen et al. [26] evaluated the ratio of reflectivity between the external limiting membrane and the ellipsoid zone by introducing a new parameter—the relative ellipsoid zone reflectivity. This metric enables assessment of the integrity of these structures while accounting for variability in reflectivity and OCT signal sensitivity, thereby rendering more reliable results.

OUTER RETINAL CORRUGATION

Outer retinal corrugations (ORCs) refer to wave-like, “ribbed” deformations of the outer portion of the retinal neuroepithelium that are clearly visualized on OCT. In recent years, these changes have been identified as a distinct morphological phenotype in RRD and are considered a potential biomarker of the disease stage and a predictor of subsequent anatomical and functional recovery (Fig. 2) [27].

Fig. 2. Spectral-domain optical coherence tomography in rhegmatogenous retinal detachment before and after vitrectomy (images from the authors’ collection): intraretinal cystic cavities are visualized in the inner and outer retinal layers, as well as low-amplitude folding of the outer layers of the retinal neuroepithelium in a patient with 22-day rhegmatogenous retinal detachment; uncorrected visual acuity = 0.05 (a). Three months after vitrectomy, the macular retinal profile appears irregular and the ellipsoid zone is poorly defined; the foveolar convexity is absent; BCVA=0.5 (b). BCVA: best corrected visual acuity.

Early descriptions of these structural alterations suggested a possible association with unfavorable functional outcomes: preoperative ORCs correlated with poorer visual acuity as early as 1 month after surgery [13]. These findings led to the hypothesis that such deformations may directly impair photoreceptor recovery; however, these conclusions were based on a small case series and limited postoperative follow-up.

In a larger retrospective study, Yeo et al. [28] further clarified the clinical significance of ORCs and demonstrated that they occur significantly more frequently when macular involvement persists for 10–30 days. In their cohort, the ORCs were more closely associated with the duration of the pathological process and were not independent predictors of visual acuity at 6 months, suggesting an indirect relationship between neuroepithelial folds and functional outcomes.

A substantial contribution to understanding the prognostic value of this OCT finding was made by the studies of Melo et al. [29, 30]. Based on both retrospective and prospective analyses, the authors proposed OCT-based stages of RRD, in which ORCs possess a prognostic value for postoperative visual acuity and serve as an early marker of a “transitional” stage. At this stage, pronounced disruption of the external limiting membrane and ellipsoid zone has not yet occurred, but there is already a risk of further degeneration of the outer retinal layers.

In the pathophysiological theory of photoreceptor and retinal pigment epithelium dysregulation proposed by Muni et al. [31], ORCs are a sign of an imbalance between the pumping function of the retinal pigment epithelium and the hydrodynamics of subretinal fluid. It has also been suggested that the persistence of wave-like deformations after anatomically successful surgery may be associated with delayed or incomplete functional recovery in some patients.

Long-term postoperative observations by Thomseth et al. [32] confirm that persistent ORCs are associated not only with poorer visual acuity but also with reduced visual quality due to metamorphopsia and aniseikonia. As the study demonstrates, regression of these folds is possible but often limited in time (up to 1–2 years) and may not occur completely. Given the relatively small study cohort and other potential confounding factors, such as the duration and initial severity of damage to the external limiting membrane and ellipsoid zone, further research is required.

INTRARETINAL CYSTIC CAVITIES

Intraretinal cystic cavities are defined as well-demarcated hyporeflective spaces within retinal layers that can be visualized using OCT [33]. In RRD, they represent a heterogeneous group ranging from transient microcysts located between the inner nuclear layer and outer plexiform layer (INL/OPL) in the early postoperative period to persistent changes characteristic of cystoid macular edema.

Intraretinal cystic cavities detected in the preoperative period (Fig. 2) are of particular importance. According to several studies [34, 35], their presence is associated with poorer functional outcomes, and a tendency toward greater central macular thickness has been observed in patients with lower final visual acuity.

It should be noted that cystic cavities are often localized within specific retinal layers, appearing predominantly in the inner nuclear layer (INL) or the outer nuclear layer (ONL). When such changes are limited exclusively to the INL and/or ONL, studies generally do not demonstrate a significant correlation with postoperative visual acuity [36]. However, investigations including intraretinal cystic cavities extending beyond these layers have reported a significant association with decreased postoperative visual acuity [37].

Large clinical studies [33, 38] confirm that cystoid macular edema following successful RRD surgery is relatively common. Risk factors include macula-off detachment, the presence of an epiretinal membrane, severe proliferative vitreoretinopathy, and early phacoemulsification (within 6 months after primary surgery).It should also be stressed that therapeutic responses to steroid and anti-VEGF (anti–vascular endothelial growth factor) agents vary considerably among these patients. This variability highlights the heterogeneous pathogenesis of cystoid macular edema in RRD and underscores the need for individualized management strategies [39]. The influence of silicone oil tamponade on cystoid macular edema remains incompletely understood. In a study by Bae et al. [40], comparative OCT analysis of macular microstructure was performed before and after silicone oil removal. The observed changes correlated with the duration of tamponade, and most structural alterations, including cystoid macular edema, resolved after silicone oil removal; however, macular surgery was performed in some patients when required.

In a study by Eibenberger et al. [41], patients with recurrent RRD and silicone oil tamponade demonstrated more pronounced morphological changes, including cystoid macular edema and epiretinal membrane formation. After silicone oil removal and reduction of edema, no statistically significant improvement in visual acuity was observed, and only the integrity of the ellipsoid zone was identified as a predictor of favorable functional outcomes.

CENTRAL MACULAR THICKNESS AND PHOTORECEPTOR OUTER SEGMENT LENGTH

Central macular thickness is defined as the distance between the internal limiting membrane and the retinal pigment epithelium measured in the foveal region. Changes in foveal thickness after successful retinal detachment surgery and their relationship with postoperative visual acuity have been widely investigated [15, 28, 29]. The available evidence suggests that foveal thickness alone cannot serve as a reliable predictor of postoperative outcomes, as the key factor is the dynamics of recovery of the outer retinal layers and the integrity of the external limiting membrane and ellipsoid zone (Fig. 1; Fig. 3).At the same time, the preoperative length of retinal photoreceptors represents an important and independent prognostic factor for functional outcomes following surgical treatment of RRD (Fig. 1 and Fig. 2). Elongation of photoreceptors during RRD is presumed to indicate preserved metabolic potential within these cells.

Fig. 3. Spectral-domain optical coherence tomography in rhegmatogenous retinal detachment before and after vitrectomy (images from the authors’ collection): thinning of the photoreceptor layer and hyporeflectivity of the external limiting membrane and ellipsoid zone are visualized in a patient with >6-month rhegmatogenous retinal detachment; uncorrected visual acuity = 0.02 (a). Three months after vitrectomy, disruption of the ellipsoid zone and the external limiting membrane with their atrophy is observed; BCVA=0.3 (b). BCVA: best corrected visual acuity.

In a retrospective study, Hirata et al. [42] performed a quantitative preoperative analysis of photoreceptor length, defined as the distance from the internal limiting membrane to the end of the photoreceptor outer segment, and evaluated its association with postoperative visual acuity. Longer photoreceptors before surgery were associated with better final visual acuity and positively correlated with the likelihood of postoperative restoration of the external limiting membrane and ellipsoid zone. These findings are also supported by Russian studies [43]. A large retrospective study by Park et al. [15] confirmed that the preoperative length of photoreceptor outer segments is an independent predictor of postoperative visual acuity. In addition, the ratio of the combined Henle fiber layer and outer nuclear layer (HFL+ONL) to the photoreceptor layer provides complementary information, while comparison with the fellow healthy eye further improves the accuracy of this OCT biomarker.

CONCLUSION

Rhegmatogenous retinal detachment remains one of the most prognostically challengingophthalmic conditions despite substantial progress in surgical treatment techniques. Current research demonstrates that OCT is a highly informative tool for detecting retinal morphological changes with potential prognostic significance.

Particular attention has been paid to the status of the ellipsoid zone and external limiting membrane, outer retinal corrugations, intraretinal cystic cavities, macular thickness, and the length of photoreceptor outer segments. These parameters may serve as biomarkers of functional recovery following surgical treatment.

However, heterogeneity of the available data, limited sample sizes, and the absence of common interpretation criteria highlight the need for further multicenter studies using standardized analytical methodologies.

Systematization of current knowledge regarding OCT biomarkers in rhegmatogenous retinal detachment may facilitate the development of reliable integrated algorithms for preoperative and postoperative assessment, as well as the individualization of surgical strategies. Ultimately, this may improve treatment outcomes and quality of life for patients.

ADDITIONAL INFORMATION

Author contributions: D.B. Babaeva, R.R. Fayzrakhmanov, E.A. Larina, concept and design definition, validation, revision, and editing of the manuscript; A.A. Daloglanyan, A.A. Zhaboev, D.A. Romanova, visualization, manuscript writing, and data collection and processing. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding sources: The study had no sponsorship.

Disclosure of interests: The authors declare no conflict of interests.

Statement of originality: The authors did not utilize previously published information (text, illustrations, data) in conducting the research and creating this paper.

Data availability statement: All data obtained in this study are available in this article.

Generative AI: Generative AI technologies were not used for this article creation.