[Aflibercept in a real-world setting: the AURIGA study : 24-month results of the German cohort of treatment-naïve patients with macular edema following retinal vein occlusion receiving intravitreal aflibercept]. / Aflibercept im klinischen Alltag: die AURIGA-Studie : 24-Monats-Ergebnisse der deutschen Kohorte behandlungsnaiver Patienten mit Makulaödem bei retinalem Venenverschluss unter Therapie mit intravitrealem Aflibercept.

BACKGROUND: AURIGA is the largest prospective real-world study to evaluate intravitreal aflibercept 2 mg (IVT-AFL) treatment of macular edema (ME) secondary to retinal vein occlusion (RVO) and diabetic macular edema. Here we present the 24-month data from the German cohort of treatment-naïve patients with ME due to RVO. METHODS: Treatment-naïve patients with ME secondary to RVO were treated with IVT-AFL 2 mg in the routine clinical practice. The primary endpoint was mean change in visual acuity (VA, early treatment diabetic retinopathy, ETDRS, letters) at month 12 compared to baseline. Analyses were descriptive. RESULTS: Analysis included 130 patients with RVO (n = 61, 46.9% with central RVO, n = 69, 53.1% with branch RVO). The mean (± SD) time the RVO patients remained in the study was 18.4 ± 7.4 months. The mean VA gain (95% confidence interval) in the overall cohort was +10.9 (7.5-14.2) letters at month 12 and +9.7 (6.1-13.3) at month 24 (baseline VA 56.5 ± 18.9 letters). At 24 months, 67% of RVO patients gained ≥5 letters and 40% gained ≥15 letters. The mean number of injections was 4.4 ± 1.3 up to month 6, 6.2 ± 2.7 up to month 12 and 8.2 ± 4.5 up to month 24. The mean central retinal thickness (CRT) reduction was -206µm (-252 to -160µm) at 12 months and -219µm (-263 to -175µm) at 24 months (baseline CRT 507 ± 177 µm). The safety profile was consistent with that of previous studies. DISCUSSION: In the German AURIGA cohort of treatment-naïve patients with ME secondary to RVO, IVT-AFL 2 mg treatment in clinical practice resulted in rapid and clinically relevant VA gains and a reduction in CRT. These results were largely maintained over 24 months despite the low injection frequency from month 6.

Real-World Management of Macular Edema Secondary to Retinal Vein Occlusion with Intravitreal Aflibercept: 24-month Results from the AURIGA Observational Study.

INTRODUCTION: AURIGA is the largest real-world study to date to evaluate intravitreal aflibercept (IVT-AFL) treatment of diabetic macular edema or macular edema secondary to retinal vein occlusion (RVO) in routine clinical practice. Here, we report the 24-month outcomes in the RVO cohort from France, Germany, Italy, and Taiwan. METHODS: AURIGA (NCT03161912) was a prospective observational study. Eligible patients with RVO were enrolled for whom the decision to treat with IVT-AFL had already been made by the attending physician. Patients were treated with IVT-AFL for up to 24 months at physician discretion according to local practice. The primary endpoint was mean change in visual acuity (VA; Early Treatment Diabetic Retinopathy Study [ETDRS] letters) from baseline to month (M) 12. All statistical analyses were descriptive. RESULTS: In 554 treatment-naïve and 65 previously treated patients with RVO, the respective mean (95% confidence interval) change in VA from baseline was + 12.5 (10.8, 14.3) and + 7.9 (3.3, 12.6) letters by M12 and + 11.4 (9.4, 13.3) and + 4.4 (- 0.6, 9.5) letters by M24 (baseline mean ± standard deviation: 51.0 ± 21.9 and 51.9 ± 20.4 letters); 44.0% of treatment-naïve and 27.9% of previously treated patients reported ≥ 15-letter gains by M24. By M24, the mean change in central retinal thickness from baseline was - 247 (- 267, - 227) µm in treatment-naïve patients and - 147 (- 192, - 102) µm in previously treated patients. From baseline to M6, M12, and M24, treatment-naïve patients received a total of 4.0 ± 1.3, 5.5 ± 2.5, and 6.9 ± 4.2 injections, respectively, and previously treated patients received 3.8 ± 1.5, 5.0 ± 2.2, and 6.3 ± 3.7 injections, respectively. The safety profile of IVT-AFL was consistent with that of previous studies. CONCLUSIONS: In AURIGA, patients with RVO experienced clinically relevant functional and anatomic improvements following IVT-AFL treatment in routine clinical practice. These improvements were largely maintained in treatment-naïve patients over the 24-month study despite the decreasing treatment frequency, suggesting long-term durability of IVT-AFL treatment outcomes. Infographic available for this article. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03161912 (May 19, 2017). INFOGRAPHIC.

Intravitreal Aflibercept for the Treatment of Diabetic Macular Edema in Routine Clinical Practice: Results from the 24-Month AURIGA Observational Study.

INTRODUCTION: AURIGA is the largest real-world study to date to evaluate intravitreal aflibercept (IVT-AFL) in the treatment of diabetic macular edema (DME) or macular edema secondary to retinal vein occlusion in routine clinical practice. The 24-month outcomes in the DME cohort from across 11 participating countries are reported here. METHODS: AURIGA (NCT03161912) was a prospective observational study. The study enrolled eligible patients with DME for whom the decision to treat with IVT-AFL had previously been made by the attending physician. Patients were treated with IVT-AFL for up to 24 months at physician discretion according to local practice. The primary endpoint was mean change in visual acuity (VA; Early Treatment Diabetic Retinopathy Study [ETDRS] letters) from baseline to month 12 (M12). All statistical analyses were descriptive. RESULTS: In 1478 treatment-naïve and 384 previously treated patients with DME, the mean (95% confidence interval) change in VA from baseline was +6.7 (5.7, 7.6) and +7.4 (5.5, 9.4) letters by M12 and +5.9 (4.9, 6.9) and +8.1 (6.1, 10.1) letters by M24 (baseline [mean ± standard deviation]: 56.0 ± 19.8 and 50.8 ± 19.5 letters), respectively; 25.9% of treatment-naïve and 32.8% of previously treated patients achieved ≥ 15-letter gains by M24. The mean change in central retinal thickness from baseline to M24 was -110 (-119, -102) µm in treatment-naïve patients and -169 (-188, -151) µm in previously treated patients. By M6, M12, and M24, treatment-naïve patients had received 3.8 ± 1.7, 4.9 ± 2.8, and 5.7 ± 3.9 injections, respectively, and previously treated patients had received 3.9 ± 1.5, 4.9 ± 2.4, and 6.2 ± 3.6 injections, respectively. The safety profile of IVT-AFL was consistent with previous studies. CONCLUSION: In AURIGA, treatment-naïve and previously treated patients with DME achieved clinically relevant functional and anatomic improvements following IVT-AFL treatment for up to 24 months in routine clinical practice. Even with the decreasing injection frequency observed, these gains were largely maintained throughout the study, suggesting long-term durability of the positive effects of IVT-AFL treatment. Infographic available for this article. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03161912 (May 19, 2017). INFOGRAPHIC.

[Internistic clarification of retinal vascular occlusions]. / Internistische Abklärung bei retinalen Gefäßverschlüssen.

Retinal vascular occlusions require close cooperation of different medical disciplines to ensure optimal care of the affected patients. The medical clarification between arterial and venous occlusions is comparable but in the case of retinal arterial occlusions it should be carried out immediately. The most important associated diagnoses are arterial hypertension, diabetes mellitus, dyslipidemia, and atrial fibrillation. In younger patients and in the absence of risk factors, a search for rarer causes should be carried out giant cell arteritis in particular should be excluded. In both types of occlusions a causative glaucoma must also be considered.

Benefit of intravitreal injections in patients with sub-threshold baseline visual acuity: a retrospective single-centre study.

PURPOSE: To investigate the lower visual acuity threshold for recommending intravitreal injection therapy (IVI). The lower limit of 1.3 logMAR best-corrected visual acuity (BCVA) was adopted in 2006 and has been maintained since then. METHODS: In this retrospective study, data from patients with a logMAR BCVA ≤ 1.3 and 24 months follow-up were analysed. We included patients with neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME), or retinal vein occlusion (RVO). RESULTS: The data from 164 patients (nAMD: 107; DME: 15; RVO: 42) were analysed. We observed a significant improvement at all time intervals (0 to 6, 6 to 12, 12 to 18, and 18 to 24 months after initiating IVI) compared to baseline. Across all indications, median BCVA improved from 1.4 to 1.0 within the first 6 months and remained stable within 24 months. Patients received a median of 5 and 10 injections within 6 and 24 months, respectively. Median foveal retinal thickness was 594.5 µm at baseline and dropped to 244.5 µm, 235.5 µm, 183 µm, and 180 µm during the four consecutive time intervals. CONCLUSION: Patients with nAMD, DME, and RVO with poor baseline BCVA may also benefit from intravitreal therapy with VEGF-inhibitors. In the present study, we observed functional and morphological improvement over 2 years irrespective of the underlying macular disease. Those patients should not be excluded from therapy.

Main Principles of Vitrectomy Using Intraocular Tamponades - A Basic Course in Surgery. / Grundlagen der Vitrektomie unter Verwendung intraokularer Tamponaden ­ ein chirurgischer Basiskurs.

This article is intended to clearly present the basic principles for the use of intraocular tamponades in vitreous/retinal surgery in the event of retinal detachment and other pathologies using additional video footage. It examines the various gases, silicone oils and perfluorocarbon liquids with their indications, administration and in particular intraoperative handling including pitfalls and complications. Characteristic animations show the principles of use in surgery in a comprehensible way. The two lead authors dedicate this article to their teacher Prof. Dr. V.-P. Gabel, who in the early 1990s successfully established the first vitrectomy courses for ophthalmologists at Regensburg University Eye Clinic each year. Many colleagues who still work in retinal surgery today first started learning about this segment on these courses. The other coauthors participated under his supervision in annual vitrectomy wet labs run by the German Academy of Ophthalmology.

Risk Factors for Severe Bleeding Complications in Glaucoma Surgery and the Role of Antiplatelet or Anticoagulant Agents.

Purpose: To evaluate the influences and risk factors for severe bleeding complications during glaucoma surgery, and to investigate the role of antiplatelet (AP) and anticoagulant (AC) agents. Methods: This prospective study enrolled patients undergoing trabeculectomy, trabeculotomy (with Trabectome® or Kahook Dual Blade®), viscocanaloplasty and Ahmed or Baerveldt implants. Bleeding severity was graded on an ordinal scale ranging from 0 to 5. Immediately after surgery and one day later, the incidence and severity of bleeding events was documented on a standardized form. A grade ≥3 was defined as severe bleeding. The influence of known systemic disorders, the type of anesthesia, surgical procedure, intraoperative blood pressure, and the use of or change in AP or AC agents on intraoperative bleeding were analyzed. Results: Data from 89 eyes undergoing glaucoma procedures were included (age 71.3y ± 10.5). We observed severe intraoperative bleeding in 8 eyes (9%) and found that concomitant diseases such as the history of a deep vein thrombosis or peripheral arterial occlusive disease, and the type of surgical procedure (trabeculectomy and viscocanaloplasty) were significantly associated with severe bleeding events. By contrast, the use of AP/ AC agents had no significant influence on severe intraoperative bleeding events. Conclusion: According to the results of our study cohort, glaucoma procedures entailing scleral manipulations (trabeculectomy and viscocanaloplasty) and concomitant diseases such as the history of a deep vein thrombosis or peripheral arterial occlusive disease influence the risk of severe intraoperative bleeding events, we detected no increased risk related to concomitant antiplatelet and/ or anticoagulant medication use.

Influence of the Size of the Foveal Avascular Zone on Functional and Morphological Parameters in Patients with Early-Stage Diabetic Retinopathy.

Purpose: To correlate functional and morphological parameters with foveal avascular zone's (FAZ) size in diabetic patients with mild to moderate stage nonproliferative diabetic retinopathy. Methods: Monocentric and prospective study of a consecutive case series of diabetic patients. Medical history, best corrected visual acuity (BCVA), best corrected high/low contrast visual acuity (BChcVA/BClcVA), mean sensitivity (MS) and mean defect (MD) in central visual field testing, and FAZ size in fluorescein-angiography (FAG) were recorded. Macular thickness (central point thickness CPT, central subfield thickness CST) and volume measurements (central subfield volume CSV, total macular volume) were taken from SD-OCT (6x6mm ETDRS-grid). Groups were categorised as presenting FAZ sizes smaller (G1) or larger (G2) than 0.35mm2. Smallest (Q1) and largest quartiles (Q3) were also compared. Results: Thirty-six of 40 patients were included. MS differed significantly between G1 (n = 6) and G2 (n = 30), and BChcVA/BClcVA as well as TMV correlated significantly with FAZ size in correlation analysis. Mean HbA1c tended to be lower in G1 than G2. Patients in G1 were slightly older than in G2. Treatment period with insulin was shorter in G1/Q1 than in G2/Q3. CPT and TMV were lower in G1/Q1 than in G2/Q3. Our analysis of the FAZ in terms of patient age, HbA1c, disease duration and insulin therapy duration revealed no significance. That lack of significance also applies to BCVA, MS, MD, CPT, CST and CSV. Conclusion: As significantly associated, contrast sensitivity, central visual field parameters and potentially retinal thickness or volume seem to be suitable to detect early macular ischaemia. However, we failed to establish any correlation between FAZ and BCVA.

[Sustainability in ophthalmology : Adaptation to the climate crisis and mitigation]. / Nachhaltigkeit in der Augenheilkunde : Adaptation an die Klimakrise und Mitigation.

The climate crisis is threatening the health of current and future generations and represents a particular challenge for healthcare systems. To address man-made climate change, comprehensive adaptation and mitigation strategies are crucial. Medicine and ophthalmology offer various opportunities to reduce the CO2 (carbon dioxide) footprint - these should be implemented and politically encouraged. Data-driven sustainability tools may provide options to evaluate the environmental footprint and to initiate optimization strategies. Life cycle assessments are an approach to systemically measure the environmental footprint and may facilitate sustainable decisions processes. The German health system needs to develop quantifiable and holistic strategies to reduce CO2; sustainability might become a future performance indicator. This article discusses examples of adaptation to the climate crisis and mitigation in ophthalmology and beyond.

A model to quantify the influence of treatment patterns and optimize outcomes in nAMD.

Neovascular age-related macular degeneration (nAMD) is a progressive retinal disease that often leads to severe and permanent vision loss. Early initiation of anti-vascular endothelial growth factor (anti-VEGF) therapy has been shown to preserve vision in nAMD patients. Concurrently, treatment outcomes in real-world are inferior to those reported in clinical trials. The most likely reasons observed are fewer treatment-intensity in routine clinical practice than in clinical trials. The other possibility could be the delay in starting treatment and the re-treatment interval. Although a negative impact of aforementioned parameters seems obvious, quantitative impact measures remain elusive in a real-world setting due to a lack of an 'optimal treatment' control group. To overcome this shortcoming, we developed, validated, and applied a model to assess and quantify the impact of anti-VEGF administration variables on visual acuity development in a prospective nAMD patient cohort. The model was further applied to probe the impact of the COVID-19 pandemic on visual progressions in nAMD patients. The presented model paves the way to systematically explore and evaluate realistic interventions in the current treatment paradigm, that can be adopted in routine clinical care.

[Avoiding mistakes in anti-VEGF intravitreal injection therapy]. / Indikationen zur intravitrealen Injektionstherapie mit Anti-VEGF für Makulaerkrankungen ­ Fehler vermeiden.

Intravitreal injection (IVI) of drugs for treatment of various macular diseases is now one of the most frequently performed surgical procedures worldwide. As mostly chronic diseases are treated, the indications for treatment often mean a continuous treatment over years with a corresponding effort regarding spatial, personnel and financial resources. The diagnosis and indications for treatment are nowadays mainly made by spectral domain optical coherence tomography (SD-OCT). The ability to clinically assess and evaluate a fluorescence angiography is less practiced, although these are still a component of the indications for intravitreal injections. Therefore, it can happen that despite all diligence patients may receive anti-vascular endothelial growth factor (VEGF) treatment, sometimes permanently, based on a misinterpretation of the macular diagnosis or disease activity and these indications, once made, are rarely questioned or retracted. Therefore, the aim of this manuscript is to point out possible and typical misinterpretations in the indications or continuation of IVI treatment with anti-VEGF by means of case studies and to sensitize for differential diagnoses.

Incidence and risk factors for macular oedema after primary rhegmatogenous retinal detachment surgery: a prospective single-centre study.

PURPOSE: To assess the incidence of cystoid macular oedema (CME) diagnosed by spectral domain optical coherence tomography (SD-OCT) after primary rhegmatogenous retinal detachment (RRD) surgery. METHODS: From April 2016 to October 2017, 150 eyes of 150 patients presenting with primary RRD were included consecutively in this prospective single-centre study. Patients with the following characteristics were excluded: previous vitreoretinal surgery, combined cataract surgery, preoperatively presentation with any intraocular or systemic inflammatory condition, visible macular oedema or epiretinal membrane (ERM) on funduscopy. SD-OCT (Spectralis, Heidelberg Engineering) was conducted 3 and 6 weeks after surgery. RESULTS: One hundred and twenty-eight of the 150 patients completed the study, of whom 107 (age: 61.7 ± 11.5 years, mean ± SD) showed successful retinal attachment during follow-up visits. The most frequent operation method was scleral buckling (54.2%), followed by vitrectomy (25.2%) and the combination of both techniques (20.6%). Postoperative SD-OCT revealed CME, neurosensory detachment and ERM in 18.7, 31.8 and 32.7% of all cases, respectively. The risk of postoperative CME was significantly elevated in patients with ERM (42.9 versus 6.9%, p < 0.001). In addition, patients with initial detachment of the macula had more postoperative CME (26.5 versus 11.1%, p = 0.044). BCVA improvement was significantly lower in patients with CME compared to patients without 6 weeks after surgery for macula-on RRD. CONCLUSIONS: This prospective study confirmed that postoperative CME is a frequent complication after RRD surgery; we identified ERM and macula-off RRD as potential risk factors. As CME potentially delays visual recovery, postoperative follow-ups should include SD-OCT.

Acute macular neuroretinopathy (AMN) following COVID-19 vaccination.

PURPOSE: To describe a case of acute macular neuroretinopathy (AMN) in a 23-year-old Caucasian female after a COVID-19 vaccination (Vaxzevira). OBSERVATIONS: Our patient perceived visual symptoms in both eyes one day after COVID-19 vaccination. Hyporeflective petalloid shaped perifoveal lesions appeared in infrared reflectance (IR) imaging, and Spectral domain-optical coherence tomography (SD-OCT) revealed structural alterations of outer retinal layers that resulted in persistent disruption of the ellipsoid zone (EZ) and the interdigitation zone (IZ). CONCLUSIONS AND IMPORTANCE: We report a novel association between AMN and COVID-19 vaccination. In addition to a febrile infection and oral contraception, previous vaccination should also be considered a potential risk factor for AMN.

Prevalence of Back Pain among German Ophthalmologists.

INTRODUCTION: The aim of this study was to evaluate the prevalence of back pain among German ophthalmologists, to investigate the relationship towards age, gender, various profession-related factors, to correlate localization of pain to subspecialties, and to explore individual therapeutic and coping strategies. METHODS: In this prospective, cross-sectional survey, a 9-item questionnaire was sent via mail to all members of the German professional association of ophthalmologists "Berufsverband der Augenärzte Deutschlands e.V. (BVA)." Responses were analyzed according to a pre-specified analysis plan. RESULTS: From a total of 5,954 members contacted, 1,861 copies (31%) were received back, of which 1,807 (30%) were suitable for analysis. 913 (51%) participants were female and 876 (48%) were male, with a median age of 50 years (interquartile range: 44; 57). 1,464 ophthalmologists (81%) reported current back problems, considerably more than had been reported in the general population or in other medical specialties. Older age, female gender, and higher number of professional years appeared to be risk factors for developing back pain. Overall, neck pain was the leading symptom in 951 attendees (65%) but differed between ophthalmologists who primarily performed conservative treatment (cervical spine) and those who performed surgery (mainly lumbar spine). 1,037 participants (71%) link their complaints to their occupational activity. Exercising and back training were reported as common strategies for prevention and coping with the problem. Recommendations for improvement were mainly ergonomic optimization of the working place. CONCLUSIONS: The prevalence of back pain complaints in German ophthalmologists is high. Neck pain (65%) was the leading localization, followed by low back pain (53%) and shoulder (38%) problems, which might emphasize a special back pain complaint profile in ophthalmologists. Low back pain seems to be more common in ophthalmologists with surgical specialization than in those with mainly medical tasks. The high prevalence of back pain in ophthalmologists should be communicated with employers, the industry, and professional societies to develop and implement a strategy to prevent occupational-related musculoskeletal disorders and preserve the ability to work and the quality of life.

Impact of the SARS-CoV-2 pandemic on ophthalmic care in Germany.

BACKGROUND: Survey by the commission for cross-sectoral ophthalmology, as a joint commission of the German Ophthalmological Society (DOG) and the Professional Association of German Ophthalmologists (BVA) on the effects of the SARS-CoV­2 pandemic on ophthalmological patient care in Germany. METHODS: Online-based survey. RESULTS: A total of 1190 questionnaires were (partly) answered. With respect to outpatient care and consultations from 15 March to 15 April 2020, a total of 69 (5.8%) participants indicated unlimited, 756 (63.5%) reduced and 330 (27.7%) emergency care only, independent of the type of institution. Outpatient surgery was restricted to emergency surgery in 68% of clinics, 42.0% of inpatient wards, 45.0% of surgical medical care centers and group practices and 33.0% of private practices. Inpatient procedures were limited to emergency care in 75.0% of inpatient wards and in 71.0% of clinics. With the exception of endophthalmitis (+8.2%), the number of urgent indications and emergencies declined: retinal detachment (-34.8%), perforating eyeball injuries (-7.3%), acute glaucoma (-17.8%), central retinal artery occlusion and anterior ischemic optic neuropathy (-31.0%), others (-30.9%), penetrating keratoplasty and amniotic membrane transplantation (-59.1%). Institutional or professional policy requirements (76.0%) and appointment cancellation by patients (84.0%) were the most common reasons for limitations in ophthalmic patient care. CONCLUSION: The initial phase of the pandemic was characterized by a massive reduction in non-urgent conservative and surgical treatment that affected all areas of ophthalmology. Due to intensive care capacities required for COVID-19 patients, inpatient treatment was largely restricted to emergencies. Treatment of ophthalmological patients, including ocular emergencies and urgent treatment, was maintained across all sectors with a (considerable) decrease in the number of cases even in these groups.

Risk Factors for Severe Bleeding Complications in Vitreoretinal Surgery and the Role of Antiplatelet or Anticoagulant Agents.

PURPOSE: To evaluate the influences and risk factors for severe bleeding complications during vitreoretinal surgery and to investigate the role of antiplatelet and anticoagulant agents. DESIGN: Prospective trial. PARTICIPANTS: Patients undergoing vitreoretinal surgery. METHODS: The procedures included were pars plana vitrectomy and scleral buckling. We developed a uniform classification to grade the bleeding severity. Bleeding was graded on an ordinal scale ranging from 0 to 5. Immediately after surgery and 1 day later, the incidence and the severity of bleeding events was documented on a standardized form. A grade of 3 or more was defined as severe bleeding. Furthermore, the influence of known systemic disorders before surgery, the type of anesthesia, type of surgical procedure, intraoperative blood pressure, and the use or change of antiplatelet or anticoagulant agents on intraoperative bleeding was analyzed. MAIN OUTCOME MEASURES: Incidence and risk factors for severe intraoperative bleeding events. RESULTS: Data from 374 eyes undergoing vitreoretinal procedures were included in our study (mean age, 67.6 ± 12.9 years). A severe intraoperative bleeding event was observed in 15 eyes (4%). We found that concomitant diseases such as diabetes mellitus and carotid artery stenosis, the presence of diabetic retinopathy, younger age, and scleral buckling combined with a transscleral puncture were associated significantly with severe bleeding events. By contrast, use of antiplatelet or anticoagulant agents, or both, had no significant influence on severe intraoperative bleeding events. CONCLUSIONS: Although external manipulations during buckling surgery (e.g., drainage of subretinal fluid) and concomitant diseases such as diabetes mellitus and carotid artery stenosis influences the risk of severe intraoperative bleeding events, we did not detect an increased risk related to coexisting antiplatelet or anticoagulant medication use, or both.

The urgency of surgical treatment for rhegmatogenous retinal detachment.

The ideal timing of surgery in patients with rhegmatogenous retinal detachment has been discussed for decades. The study situation has improved in recent years so that recommendations can now be made. When the macula is detached, surgical treatment of the retinal detachment should be undertaken within a few days. When the macula is still attached, the near fovea and bullous superotemporal detachment should be classified as an emergency. When planning the operation environmental factors must also be considered, meaning that the performance of the intervention by an experienced surgical team is usually more important for the final result than the retinal condition alone. Influencing factors are discussed in this article and recommendations for dealing with these emergency patients are discussed.