Drag and drop: a narrative review of foveal and retinal displacement in clinical practice

Introduction

Background

The fovea is the central region of the retina that provides high visual acuity. Foveal development begins at 24–25 weeks of gestation and involves bidirectional migration of the outer and inner retinal layers, specifically, centrifugal migration of the inner retina and centripetal migration of the outer retina, followed by postnatal maturation of the outer retina (1-4). This process results in the formation of an area devoid of inner retinal layers and vessels, thereby minimizing light scatter. However, the normal functional role of the retina and fovea can only be maintained when they are properly aligned with the optical axis of the eye. At the same time, in certain diseases, unsatisfactory functional status is observed despite preserved anatomical integrity of the retina, a situation which may be explained by retinal and/or foveal displacement (5-7).

Rationale and knowledge gap

Changes in retinal topography may accompany a wide range of congenital and acquired conditions. Currently, retinal and foveal displacement are actively discussed in the context of diseases requiring surgical treatment, primarily involving vitreoretinal interface pathology, including epiretinal membrane (ERM), full-thickness macular hole (FTMH), and rhegmatogenous retinal detachment (RRD). Despite a substantial body of accumulated evidence, we have not identified any studies that synthesize the existing data.

Objective

Therefore, the aim of our study was to summarize the information about retinal and foveal displacement, the conditions associated with this phenomenon, the methods of its assessment, and to evaluate its association with anatomical and functional status pre- and postoperatively. We present this article in accordance with the Narrative Review reporting checklist (available at https://aes.amegroups.com/article/view/10.21037/aes-2026-0032/rc).

Methods

In our work, we reviewed all English-language literature reporting methods for assessing foveal morphology, foveal and retinal displacement in ERM, FTMH, RRD, retinopathy of prematurity (ROP), familial exudative vitreoretinopathy (FEVR), and inherited conditions as well as the nature of displacement and associated visual function impairment in these conditions. An electronic literature search was conducted using the PubMed and Google Scholar databases. We included peer-reviewed articles describing clinical and basic science research between April 2025 and March 2026. The following search terms were used in the context of retinal and foveal displacement: “retinal displacement”, “foveal displacement”, “fovea-to-disc distance”, “fovea-to-disc angle”, “epiretinal membrane”, “full-thickness macular hole”, and “rhegmatogenous retinal detachment” (Table 1). Observational and interventional studies were included, comprising randomized and non-randomized clinical trials, retrospective and prospective case-control or cohort studies. Case reports, conference abstracts, meeting proceedings, duplicate publications, unpublished materials, and editorials were excluded. A manual search of the reference lists of the selected articles was also performed to identify possible relevant studies. Three authors (D.S.M., Y.A.K., V.A.Z.) independently assessed study quality by evaluating consistency between the title, abstract, and full text. A fourth investigator (A.N.K.) made the final decision when consensus could not be reached between the three aforementioned authors.

Among the selected sources, we analyzed information on foveal morphology in healthy eyes and in various diseases, methods for visualizing retinal and foveal displacement, and evaluated the characteristics of this phenomenon in eyes with ERM, FTMH, and RRD, as well as its relationship with functional status.

Normal foveal center microstructure alignment

Knowledge of normal foveal microanatomy is essential for determining its exact position since it is the foveal center, not the entire fovea, that provides high visual acuity and should be used for topographical evaluation.

The fovea is located in the central part of the macular area and represents a region approximately 1,500 µm in diameter [1 disc diameter (DD)], situated 2–2.5 DD temporal to the optic disc (8). On color fundus photography, the fovea appears as a small, darkish area surrounded by a lighter, glistening ring (the macular reflex) related to light reflection from the internal limiting membrane (ILM).

The central element of the fovea is the foveola, characterized on cross-sectional optical coherence tomography (OCT) by the absence of inner retinal layers, increased thickness of the outer nuclear layer (ONL), and the presence of a foveal bulge. The foveal bulge is a dome-shaped elevation of the ellipsoid zone, characterized by thickening of the photoreceptor outer segments (9,10). Preservation of the foveal bulge, external limiting membrane, ellipsoid zone, and interdigitation zone correlates with visual acuity in various retinal diseases (5-7,9,11,12). On cross-sectional OCT scans, landmarks for the foveal center include the foveolar ILM reflex, the deepest point of the foveola, the point of maximal ONL thickness, and the foveal bulge (13). Additional landmarks for positioning the foveal center may include not only the foveal anatomical structures themselves but also the surrounding microvasculature (Figure 1).

Figure 1 Microanatomy of the foveal center based on OCTA. (A) OCTA projection of the full retina slab shows asymmetry of foveal avascular zone in relation to the foveal bulge marked by the cross section of white and yellow dashed lines. (B) Vertical cross-sectional scan showing vertical position of the foveal bulge (asterisk). (C) Horizontal cross-sectional scan showing horizontal position of the foveal bulge (asterisk) and its misalignment with the foveal reflex (arrowhead). OCTA, optical coherence tomography angiography.

Due to the absence of inner retinal layers and consequently of retinal vascular plexuses in the foveola, the foveal avascular zone (FAZ) can be visualized on en face optical coherence tomography angiography (OCTA) images or on fluorescein angiography. In the healthy population, FAZ size ranges from 0.05 to 1.05 mm² (3). Variability in FAZ morphology among healthy individuals is also possible, including the presence of macular-foveal capillaries and congenital retinal macrovasculature in the fovea (affecting approximately 4% of patients) (14).

Topographical analysis has revealed a misalignment between the FAZ center, the foveal center, and the foveal bulge in 85.6–95% of healthy subjects, with the latter predominantly shifted nasally relative to the horizontal axis (10,13,15,16). Hasegawa et al. and Nesmith et al. reported that the FAZ center may shift superiorly and temporally relative to the foveal bulge in older individuals without loss of visual acuity (16,17). At present, the mechanism underlying the formation and significance of this topographical dissociation between the foveal center and the foveal bulge remains unknown, partly due to a lack of precise understanding of their role in establishing the fixation point. This phenomenon may have implications in planning surgical (particularly laser) interventions near the fovea, a question that warrants further investigation.

Optic disc-to-fovea distance

Given the absence of other stable anatomical landmarks on the fundus, quantitative assessment of foveal position relative to the optic disc is an important tool for analyzing foveal location. The main parameters analyzed are the fovea-to-disc distance and the fovea-to-disc angle.

The fovea-to-disc distance is measured as the distance from the foveal center to the optic disc center. The foveal center is identified by the foveolar reflex. If absent it can be determined by the center of the macular reflex, and if that is also absent, by the FAZ center, which can be further refined using OCTA. The optic disc center is defined as the intersection point of two lines connecting the superior-inferior and lateral disc margins, respectively (18,19). Fovea-to-disc distance values are not constant and can vary among healthy eyes, ranging from 3.88 to 4.9 mm (8,20,21).

Increased axial length is associated with enlargement of both the horizontal and vertical diameters of the eye, leading to an increase in the fovea-to-disc distance and disc size (18,22-24). Qiu et al. demonstrated that the fovea-to-disc distance is inversely related to retinal nerve fiber layer (RNFL) thickness, which corresponds to lower RNFL thickness values in patients with axial myopia (21,25-27). At the same time, longer axial length and consequently larger fovea-to-disc distance lead to increased thickness of the temporal RNFL portions (28) and are associated with greater severity of myopic maculopathy (the risk increases when the fovea-to-disc distance exceeds 5.15 mm) (29). It should be noted that axial length influences transversal image magnification (30) and may therefore cause overestimation of the fovea-to-disc distance.

Foveal location and cyclotorsion

The fovea-to-disc angle provides additional information on the vertical position of the optic disc relative to the fovea. Several methods exist for measuring this parameter. Most commonly, the reference lines are a horizontal line drawn through the optic disc center (in modern approaches, through the Bruch membrane opening) (31-33), less frequently through the foveal center (25,34,35), and the line connecting the foveal center and the optic disc center. Mean values range from −5.6° to 7.8° (negative values may be recorded when the fovea is located below the optic disc center) (18,22,31). However, the fovea-to-disc angle and in general the position of the fovea in relation to the optic disc and horizontal axis may be substantially affected by torsional eye movements.

The physiological foveal position (physiological or basal cycloposition) is located 3–4 mm lateral to the optic disc on the horizontal axis and 0.8 mm below the optic disc center on the vertical axis (6.1±3.3°) (8). Landmarks for the physiological vertical position of the fovea relative to the optic disc are the optic disc center superiorly and its inferior margin inferiorly (0.5° upward and 12.7° downward from the horizontal line passing through the disc center) (8). A foveal location below the disc is termed excyclotorsion, whereas a location above the disc center is termed incyclotorsion (32). When measurements deviate from normative values, one should consider the influence of both pathological and physiological factors on this parameter.

Optic disc cyclodeviations arise primarily from pathological conditions associated with dysfunction of the extraocular muscles (32,36). Physiological cyclotorsion refers to eye movements around the anteroposterior axis in the direction opposite to head tilt. This phenomenon, known as cyclovergence, results from the vestibulo‑ocular reflex and serves to stabilize the perceived image (36). Cyclovergence is independent of age and sex and occurs during head tilts to the side in an amplitude of approximately one-sixth of the degree of head tilt. It is characterized by incyclotorsion of the ipsilateral eye and excyclotorsion of the contralateral eye. Cyclovergence is not observed during rotations of the head around the frontal or vertical axes (35). Small-amplitude tilts (up to 10°) are compensated by torsional eye movements in 26–45% of cases. With increasing tilt amplitude, the proportion of cases showing compensation decreases to 13–22% (compensation degree is assessed by the difference in the angle measured in the upright position versus during head tilt) (37,38). Each 1° of head tilt changes the fovea-to-disc angle by 0.76° (39).

Thus, head tilts can induce binocular vertical deviation of the optic disc relative to the fovea, introducing additional complexity into data analysis due to the loss of the contralateral eye as a physiological reference. Therefore, it is important to ensure that the patient’s head is vertically aligned during study procedures to avoid obtaining erroneous results.

Interocular asymmetry

Even among healthy individuals, foveal characteristics vary considerably, making the fellow eye an attractive reference for assessing unilateral foveal pathology. For example, analysis of macular and foveal architecture has demonstrated bilateral symmetry in ONL thickness, photoreceptor organization, and the position of the foveal bulge relative to the foveal center (13,40).

The high interocular correlation of foveal structural organization is accompanied by high symmetry of foveal topography relative to the optic disc. The correlation of fovea-to-disc distance between eyes is 0.958 (41). Interocular differences in vertical deviation are also small (the mean difference in the fovea-to-disc angle between eyes is 1.1°±1.4°). A difference in angle values between the right and left eye exceeding 4° is not physiological and often indicates muscular dysfunction (42). The change in the fovea-to-disc angle due to head tilt is 0.76° for the right eye and 0.77° for the left eye per 1° of head tilt, with no statistically significant difference between the two eyes (39).

In a study of 236 healthy eyes Liu et al. demonstrated no difference in foveal microcirculation between the two eyes, reflected in bilateral symmetry of FAZ area (interocular difference of 0.002±0.037 mm² for the superficial capillary plexus FAZ) and foveal density (43). Ocular dominance does not influence structural and topographic parameters (39).

The high bilateral symmetry of foveal architecture suggests that the fellow eye could be used as a reference when assessing foveal morphology in the affected eye, both preoperatively and postoperatively. At the same time, further studies are needed to evaluate the variability of the described parameters in the presence of interocular differences in refraction and axial length.

Foveal displacement in inherited conditions and the role of axial length

Since retinal and foveal development occurs postnatally, an atypical foveal position may be part of congenital conditions or may develop as a result of postnatal diseases. The ratio of fovea-to-disc distance to optic disc diameter is part of the clinical picture of optic nerve hypoplasia, one of the leading causes of low vision in children. This parameter was first introduced by Awan. According to this study, a ratio greater than 3.0 indicates a high risk of optic nerve hypoplasia, while a ratio of 4.0 or higher suggests the presence of hypoplasia (44,45). The validity of this finding has since been confirmed by several other studies (44,46,47). Given that both fovea-to-disc distance and optic disc diameter depend on age and axial length (48), these parameters should be taken into consideration.

Because retinal vascularization is closely linked to foveal development and emerges from the optic disc toward the periphery, the fovea-to-disc distance is a key parameter in the classification of ROP (49). Increased axial length equally affects the change in fovea-to-disc distance in both premature and full-term children. The increase in fovea-to-disc distance with increasing axial length therefore enlarges zone I, which should be taken into account when classifying the disease (50).

An important phenomenon that may occur in patients with inherited and congenital diseases is foveal ectopia. This term refers to foveal localization beyond 2 to 3 DD from the temporal edge of the optic disc horizontally or outside the range of 0.5° above and 12.7° below the horizontal line passing through the optic disc center (8,51). Foveal ectopia occurs predominantly in the context of ROP (Figure 2), FEVR (Figure 3), and combined hamartoma of the retina and retinal pigment epithelium (RPE). Foveal ectopia results from “dragging” of the neurosensory retina toward a peripheral focus of vitreoretinal traction, which in turn negatively affects the functional status of these eyes (52-54). In FEVR the fovea-to-disc distance correlates with disease severity, the presence of avascularity, and is accompanied by reduced optic disc size and decreased vessel density and may serve as an indicator of peripheral traction (53,55).

Figure 2 Foveal displacement in an adult patient with retinopathy of prematurity. (A) Pseudo-SLO image showing localization of the foveal center (asterisk) in relation to the optic nerve head and position of cross-sectional scan in C. (B) OCTA projection of the full retina slab shows normal distance between the foveal center and the optic disc center (yellow arrow). (C) Horizontal cross-sectional scan showing the horizontal position of the foveal center (arrowhead). (D) Pseudo-SLO image showing localization of the foveal center (asterisk) in relation to the optic nerve head, severely distorted retinal vessels, and position of cross-sectional scan in F. (E) OCTA projection of the full retina slab showing a shortened distance between the foveal center and the optic disc center (yellow arrow). (F) Horizontal cross-sectional scan showing the horizontal position of the foveal center (arrowhead). OCTA, optical coherence tomography angiography; SLO, scanning laser ophthalmoscopy.

Figure 3 Foveal displacement in familial exudative vitreoretinopathy. The foveal center is displaced in the downward and temporal direction (yellow arrow). Increased fovea-to-disc distance equals 5 DD (black circles). DD, disc diameter.

Methods for evaluating foveal and retinal displacement

Since foveal dislocation may reflect general dislocation of the neurosensory retina, measuring only the fovea-to-disc distance and angle may be insufficient. Additional landmarks are needed to quantify retinal ectopia and enable longitudinal follow-up. Retinal vessels, being easily visualized and inevitably involved in displacement, have become the main markers for assessing tractional deformation. A variety of techniques, including color fundus photography, infrared imaging, scanning laser ophthalmoscopy (SLO), OCT, and OCTA, are now used to evaluate foveal and retinal displacement (Table 2).

Color fundus photography and scanning laser ophthalmoscopy

Color, infrared, or red-free fundus imaging are the simplest methods for analyzing retinal displacement. Existing techniques involve quantitative assessment of the displacement of retinal vessels relative to the fovea, optic disc, or both. To improve the accuracy of alignment and comparison of images obtained during follow-up, choroidal vessels (which are not involved in tractional retinal deformation) and the optic disc have been proposed as reference landmarks (56-58).

A wide range of approaches have been described for quantifying retinal displacement using SLO. Ichikawa et al. used SLO to measure the distance between small-caliber vessels located within the ERM area in four quadrants of the macula. Vessels were selected so that lines connecting the superior, inferior, temporal, and nasal vessels were strictly vertical or horizontal and passed through the macular center (59).

More commonly used methods assess vessel displacement relative to the fovea or optic disc, often combined with measurements of the distance between these structures. When analyzing vessel position relative to the optic disc, linear distances are used, such as the distance from the temporal disc margin to vessel bifurcations of the vascular arcades in the superior- or inferior-nasal quadrants (60), or to intersections of smaller vessels in the nasal and temporal quadrants or four quadrants of the macula (61-63). When studying vessel ectopia relative to the fovea, distances from the foveal center to bifurcations of the vascular arcades in the superior-nasal or inferior-nasal quadrants (64) or to retinal vessel intersections are measured (65).

Several studies have focused on vector analysis of retinal displacement (56,57). The retinal displacement vector is assessed based on the direction of vessel ectopia, for example, by dividing the macular area into quadrants, in each of 9 squares within 30° (57), or in each of 25 squares within 20° (56). Pak et al. proposed measuring vessel displacement within sectors of a grid placed over the macular area, which consisted of two rings each containing eight sectors, with inner and outer ring diameters of 2–4 mm and 4–6 mm, respectively (66). Park et al. introduced a novel method for assessing macular displacement using a 6 mm × 6 mm square grid placed over the macular area (67). Based on images obtained over time, the grid boundaries are adjusted according to vessel position. Yang et al. suggested evaluating the retinal area between the main vascular arcades and the macroscopic divergence angle (68).

Lee et al. developed a novel model for assessing retinal displacement in ERM that takes into account not only the topographic relationships between the fovea, optic disc, and major vascular arcades, but also the relationship between the ERM and the neurosensory retina (69). The measured parameters include the disc-fovea-vessel distance and the membrane-traction index. The disc-fovea-vessel distance is the sum of the fovea-to-disc distance and two perpendiculars from the foveal center to the superior and inferior temporal vascular arcades. Retinal displacement can also be assessed by measuring the distance from the foveal center to retinal vessel bifurcations in four quadrants within 2 DD (70).

Optical coherence tomography

The introduction of OCT and OCTA into routine clinical practice has enabled precise identification of the foveal center even in the presence of substantial morphological alterations. In this context, the key landmarks for assessing foveal position are the inner surface of the foveal depression or the area of inner nuclear layer thickening.

Kofod et al. determined the exact foveal position on structural OCT scans and extrapolated these data to follow-up infrared fundus images. The foveal position was then assessed using a coordinate system, and the degree of foveal ectopia was determined based on the difference in position (57). Changes in foveal position can also be assessed by the distance between B-scans of the scan pattern along the vertical or horizontal axis through the foveal center during follow-up (71). However, in some cases, such as the presence of a macular hole, flattening of the foveal pit, or central migration of the inner retinal layers due to ERM, determining the foveal center becomes challenging. Therefore, for macular holes, the center of the hole is conventionally considered the foveola, and for stage 2 or higher ERM, the point of greatest ONL thickness is used (72).

Since foveal displacement is often accompanied by disruption of the retinal layer architecture, analysis of microstructural changes in the fovea is important for assessing the correlation between foveal displacement and the degree of functional impairment, as well as for determining the prognosis for visual recovery. Zhang et al. and Sakai et al. investigated tractional changes at the foveal level (73,74). Tractional displacement is calculated based on cross-sectional OCT scans and is defined as the product of the length of a line drawn from the RPE at the foveal center to the foveal center in the inner retina at the point of greatest ONL thickness and the cosine of the angle between this line and the RPE line (74). The position of the foveal center in the inner retina relative to the center in the outer retina along the horizontal and vertical axes reflects the degree of foveal displacement.

In contrast to fundus images, en face OCTA images provide more detailed visualization of the retinal microvasculature which, combined with the ability to simultaneously analyze structural changes, has found application in assessing retinal displacement. Tsukahara et al. adapted the Ichikawa method, originally developed for infrared fundus images, to en face OCTA images (3 mm × 3 mm) of the superficial capillary plexus and proposed measuring distances both between vessel bifurcations near the fovea and outside the Early Treatment Diabetic Retinopathy Study (ETDRS) grid to calculate retinal displacement (75). The method described by Akahori et al. involves analyzing dynamic changes in the distance from the optic disc to retinal vessel bifurcations in the superficial capillary plexus on en face OCTA images (3 mm × 3 mm), the angle between this distance and the fovea-to-disc distance, as well as the distance from the foveal center to vessel bifurcations (76). Allegrini et al. proposed assessing retinal relaxation after surgical treatment of ERM by comparing the position of superficial capillary plexus vessel intersections on OCTA and SLO during postoperative follow-up (77). The projection of retinal vessel intersections onto the RPE 6 months postoperatively was taken as the reference position.

Advances in computer technology have enabled the development of software for image processing which minimizes errors and inaccuracies in image alignment and reduces the subjectivity of manual measurements. In particular, retinal displacement assessment using OCT homography, which involves automated overlay and alignment of infrared images converted to red and green channels, is increasingly reported in the literature (58,66,78,79).

Fundus autofluorescence

Widefield and ultra-widefield fundus autofluorescence (FAF) has led to the identification of a new biomarker of retinal displacement, termed “retinal vessel prints” (80) or “ghost vessels” (81). This phenomenon was first described by Shiragami et al. in patients after RRD surgery and was later discussed in the context of vitreoretinal pathology (82,83). On FAF images, it corresponds to hyperfluorescent lines running alongside hypofluorescent major retinal vessels, mirroring their course. It is hypothesized that the hyperfluorescent lines reflect the position of retinal vessels before surgery and are related either to altered RPE metabolic activity and excessive fluorescence (82), or to an imbalance of fluorophores (84) in areas previously shielded by major retinal vessels.

Several researchers have attempted to quantitatively analyze retinal displacement on FAF images to establish correlations with anatomical and functional status. Rodrigues et al. measured the distances between the foveal and optic disc centers, as well as the interarcade distance and the “perimacular area”. The latter was defined as the area between lines connecting the terminal vessel bifurcations in each of the four quadrants within 2 DD from the fovea (83).

Lee et al. proposed assessing the degree of vessel displacement using concentric measurement circles ranging from 1 to 10 DD, centered on the optic disc center (81). Retinal displacement corresponds to the distance between the intersection point of a “retinal vessel print” with the circle and the native vessel. Dell’Omo et al. suggested dividing the image into 15 sectors, manually delineating the area between the retinal vessel print and the native vessel in each quadrant, and then calculating its area (84). Bhambra et al. proposed assessing the vessel displacement vector based on the vertical, horizontal, and diagonal distances between corresponding points on the native and “ghost” vessels within a circle centered on the fovea with a radius equal to the fovea-to-disc distance (85).

However, due to the limitations of this method, it is believed that the magnitude of displacement measured by autofluorescence may not fully represent the true extent of retinal displacement (78).

Foveal and retinal displacement in surgical pathology

Unsatisfactory functional outcomes are a major challenge in vitreoretinal surgery. These may manifest not only as suboptimal visual acuity, but also as metamorphopsia and impaired binocular vision. While the postoperative morphological status of the fovea may explain some unsatisfactory results, foveal displacement also plays an important role.

Epiretinal membrane

ERM is closely associated with tractional retinal deformation and a number of microstructural changes that lead to reduced visual acuity and metamorphopsia (predominantly macropsia). Tangential traction primarily leads to dislocation of the inner retina. However, it is believed that visual function impairment results from damage to the outer retina. The influence of inner retinal tractions on the architecture of the entire retina and its functions therefore remains not fully understood.

Numerous methods have been developed to assess the degree of tractional retinal deformation by evaluating dislocation of the fovea and retinal vessels of various calibers using infrared SLO and color photography (56,59,69,84). It has been established that the rate of decrease in fovea-to-disc distance is higher in eyes with ERM compared to contralateral healthy eyes, and this correlates with the functional status of these eyes. However, tangential vessel displacement may occur even without changes in visual acuity (57,72). A decrease in the disc-fovea-vessel distance in eyes with initially high visual acuity is associated with an increased rate of visual deterioration over 2 years (69) (Figure 4).

Figure 4 Foveal displacement in epiretinal membrane. (A) Pseudo-SLO image in the eye with ERM showing localization of the foveal center (asterisk) in relation to the optic nerve head and position (dashed line) of cross-sectional scan in G. (B) OCTA projection of the full retina slab shows shortened distance between the foveal center and the optic disc center (yellow arrow) and downward displacement of the center of the fovea. (C) Structural en face projection of epiretinal slab shows ERM. (D) Pseudo-SLO image in healthy fellow eye showing localization of the foveal center (asterisk) in relation to the optic nerve head and position (dashed line) of cross-sectional scan in F. (E) OCTA projection of the full retina slab showing normal distance between the foveal center and the optic disc center (yellow arrow). (F) Horizontal cross-sectional scan showing position of the foveal center in healthy fellow eye. (G) Horizontal cross-sectional scan showing position of the foveal center in the eye with ERM. ERM, epiretinal membrane; OCTA, optical coherence tomography angiography; SLO, scanning laser ophthalmoscopy.

Vitrectomy with ERM removal and ILM peeling eliminates the tractional component and leads to reverse displacement of the neurosensory retina. The greatest amplitude of reverse displacement is observed in the first month after surgery and decreases by 6 months of follow-up (83.6±30.3 µm at 1 month and 39.1±22.8 µm at 6 months). However, the fovea may not return to its physiological position (77,79,86). Retinal displacement occurs in all sectors of the macula, and its magnitude correlates with the distance from the fovea (79,87). An additional phenomenon that helps visualize retinal displacement is the presence of “retinal vessel prints” on FAF. In the context of ERM, this marker is a transient finding that resolves after reduction of traction (84).

Metamorphopsia is one of the leading complaints among patients with ERM, impairing quality of life. While visual acuity mainly depends on the status of the photoreceptors (88), the severity of metamorphopsia is determined by the direction and degree of retinal displacement (56,86). Vertical metamorphopsia is predominantly observed in eyes with horizontal retinal displacement, as the latter is associated with vertically oriented deformation, whereas horizontal metamorphopsia occurs with vertical displacement (56,74). Sakai et al. introduced the concept of tangential foveal deformation which reflects the displacement vector of the ONL in ERM (74). According to their study, displacement occurs predominantly in the horizontal direction (24.0±73.9 µm compared to 6.0±76.2 µm in the vertical direction), and the degree of displacement correlates with the severity of metamorphopsia. Metamorphopsia is detected in 90% of patients with FAF retinal vessel prints and is associated with more severe disruption of the external limiting membrane and ellipsoid zone, and consequently with lower visual function (84). Resolution of metamorphopsia postoperatively begins earlier than recovery of visual acuity, and the rate of recovery correlates with the severity of the initial traction. It is known that gradual improvement of metamorphopsia can be observed as early as 1 week after surgery and, in cases of vertical metamorphopsia, reaches a maximum by 3 months of follow-up (59,89). Currently, the correlation between the type of metamorphopsia and the direction of postoperative retinal displacement remains an open question. Horizontal metamorphopsias mostly depend on preoperative retinal deformation and may therefore persist for up to 1 year (59,74,79,89). Dynamic parameters positively associated with recovery of visual acuity and reduction of metamorphopsia include postoperative decrease in central retinal thickness (CRT) (in particular, reduction in ONL thickness) and increases in distances between retinal vessels (both major arcade vessels and small-caliber vessels) (59,90). The degree of foveal displacement is an additional prognostic factor for visual outcomes following ERM treatment. The maximum regression of foveal displacement occurs in the first postoperative month and is completed by the first year of follow-up. If the fovea shows temporalization preoperatively, it dislocates horizontally toward the optic disc postoperatively. The degree of displacement correlates with the severity of inner retinal layer ectopia, CRT, and consequently with long-term functional status (58,72).

Macular hole

Although there are no data on retinal displacement during the natural course of the macular hole, vitrectomy with ILM peeling performed for treatment of this condition may be associated with postoperative foveal displacement.

Kawano et al. and Nakagomi et al. were the first to demonstrate that in patients with an FTMH, postoperative displacement of the macular retina toward the optic disc occurs and is accompanied by a reduction in the FAZ area (65,91). Dislocation begins after surgery and reaches a maximum by 2 weeks of follow-up, accompanied by a decrease in the distance between the macular hole/foveal center and the optic disc, as well as a reduction in the distance from the macular hole/foveal center to vessel intersections or bifurcations of the vascular arcades (65,76,91). The reason for this phenomenon remains unknown. It is hypothesized that postoperative dislocation of the neurosensory retina is related to contraction of the RNFL and loss of structural support from the removed ILM, making the retina more elastic and mobile (62). This theory is supported by the following observations. First, retinal displacement occurs predominantly in the parafoveal area, with greater amplitude in the temporal sector (the region of retinal relaxation following ILM removal), resulting in a centripetal vector of defect closure. Second, foveal displacement is absent in patients with spontaneous closure of a macular hole (62,65). In addition to nasal displacement, Akahori et al. noted a slight downward shift, which may be related to secondary dislocation caused by gas during tamponade (76) (Figure 5).

Figure 5 Foveal center displacement after macular hole surgery. (A) Structural en face projection of the choroidal slab showing the position of the macular hole center (intersection of the green and red lines) preoperatively. (B) Structural en face projection of the choroidal slab showing downward displacement of the macular hole center (intersection of the green and red lines) postoperatively. The preoperative position of the macular hole center is indicated by the asterisk. (C) Cross-sectional OCT scan showing the macular hole preoperatively. (D) Cross-sectional OCT scan showing complete closure of the macular hole postoperatively. OCT, optical coherence tomography.

The size of an FTMH may predict the degree of postoperative foveal displacement. Larger basal hole diameter is associated with greater foveal displacement (particularly nasally) and consequently with more pronounced visual disturbances in the postoperative period (62,64,66,75,76). This is likely because larger FTMHs are accompanied by greater centrifugal displacement of photoreceptors, reducing the likelihood of restoring their physiological organization (75).

The extent of ILM peeling may influence the magnitude of macular displacement. Several studies have demonstrated that the inverted temporal ILM flap technique results in less foveal displacement, faster recovery, and quicker visual improvement than conventional 360° ILM peeling (60,66,92). Furthermore, dissociation of the RNFL is associated with a greater reduction in the fovea-to-disc distance (5.6%±1.7% vs. 1.4%±1.1%, respectively, for temporal and 360° ILM peeling) (91). However, a smaller area of ILM peeling is associated with foveal asymmetry on cross-sectional OCT scans and with a higher risk of persistent metamorphopsia during 6 months of follow-up (67,93). Thus, reducing the area of ILM peeling decreases the amplitude of foveal displacement and the occurrence of RNFL dissociation but increases the risk of residual metamorphopsia.

It remains unknown whether cystic changes at the edges of an FTMH influence the degree of foveal displacement. Additional studies are also needed to investigate the association between visual function changes and the magnitude of retinal ectopia, as well as the morphometric parameters of an FTMH.

Retinal detachment

Despite the high anatomical success rate of existing RRD treatments (over 90%) (94), some patients experience persistent metamorphopsia and low visual acuity postoperatively, which significantly impair quality of life. The leading causes of this phenomenon are photoreceptor alteration and retinal displacement (95).

FAF performed with a fundus camera or SLO is the primary method for assessing retinal displacement in patients with RRD (96). The key sign of postoperative retinal displacement is “retinal vessel prints” (80) or “ghost vessels” (81). The topography of this sign varies depending on the etiology. Visualization of this biomarker on one side of the arcade vessels suggests RRD (above the arcades indicates inferior RRD, below the arcades indicates superior RRD). In turn, the presence of the sign below the superior-temporal arcade and above the inferior-temporal arcade suggests prior tractional deformation of the macular retina (84). Such topography of the phenomenon indicates a predominantly vertical vector of displacement (97) (Figure 6).

Figure 6 Ghost vessels after successful retinal detachment surgery. (A) Fundus autofluorescence image showing retinal vessel traces superior to the actual position of the retinal vessels (arrows). (B) Structural en face projection of the RPE slab in the healthy fellow eye, showing the foveal center (asterisk) and the position of the cross-sectional scan (green line) in D. (C) Structural en face projection of the RPE slab in the eye after successful retinal detachment surgery, showing the foveal center (asterisk) and the position of the cross-sectional scan (green line) in E. The foveal center is displaced downward, corresponding to the appearance of foveal vessel traces on the fundus autofluorescence image. (D) Transfoveal cross-sectional scan in the healthy fellow eye. (E) Transfoveal cross-sectional scan in the eye after successful retinal detachment surgery. RPE, retinal pigment epithelium.

Given the important role of retinal displacement in achieving optimal functional outcomes, several studies have focused on identifying factors associated with its occurrence (81,84,98-100). This phenomenon occurs in patients with RRD involving the macula and is not associated with the duration of detachment, the location of retinal breaks, or patient age (82,84,101,102).

Overall, retinal displacement occurs on average in 35% of RRD cases (97), with the percentage varying depending on the surgical method: 4.3–6.7% after pneumatic retinopexy (99,103,104) and 31–68% after vitrectomy (99,100,103,104). According to several studies, pars plana vitrectomy with gas tamponade is associated with retinal displacement in 41.2–72% of cases (81,82,105,106), whereas silicone oil tamponade results in displacement in only 4.5–22.2% of cases (105-108). The lower likelihood of displacement with silicone oil tamponade is probably related to the physical properties of silicone oil: its specific gravity, surface tension, and buoyancy. Therefore, an equivalent volume of gas exerts more intense and rapid force on the retina, leading to neurosensory retinal dislocation (105). This is supported by the lower displacement rate (7–15%) with pneumatic retinopexy, which uses a smaller gas volume (100,109,110). Moreover, faster, more aggressive neurosensory retinal adhesion to the RPE during gas tamponade displaces more subretinal fluid to adjacent areas, accumulating a larger volume of fluid at the gas-fluid interface, which stretches the retina and leads to its displacement, further exacerbated by gravity-induced movement of subretinal fluid (105,109). In general, forced reduction of subretinal fluid volume by drainage increases the likelihood of postoperative dislocation. Maintaining a face-down position for at least 24 hours in the early postoperative period reduces both the likelihood and amplitude of retinal displacement (81,82,98,100,106). However, few studies have evaluated the severity of retinal displacement and functional status in relation to the volume of subretinal fluid, the rate of RRD progression, the degree of preoperative proliferative vitreoretinopathy, or the impact of retinotomy.

Vorobichik Berar et al. graded the severity of retinal displacement based on the distance between the “retinal vessel print” sign and the native vessels (103). According to their study, in stage 1, hyperautofluorescence is visualized along the edge of the retinal vessel. In subsequent stages, the native and ghost vessels are separated: in stage 2, by <2 vessel diameters, and in stage 3, by >2 vessel diameters. Stages 2 and 3 predominate in patients following pars plana vitrectomy and are inversely correlated with functional status (81,96,103). Although the presence of retinal displacement does not substantially affect visual acuity (103,105,111,112), other disturbances such as metamorphopsia and aniseikonia vary widely (81,100,104). Moreover, RRD involving the macula with pronounced metamorphopsia may be associated with impaired fusion and the development of binocular diplopia (81,105,108,113). Functional disturbances persist throughout the follow-up period, correlating with outer retinal status and stable persistence of the “retinal vessel print” sign for up to 1 year of observation (9,95,98,105). However, some studies suggest that the sign may change over longer follow-up periods (82,101).

Persistent subretinal fluid and outer retinal folds are common postoperative complications of RRD that cause metamorphopsia and delay visual rehabilitation. Given the pathogenetic basis of retinal displacement, it is logical to assume an association between these phenomena and retinal displacement. The lower incidence of outer retinal folds after pneumatic retinopexy (114-116) or after vitrectomy, with face-down positioning (98,103,105), provides indirect evidence of such an association. Additional studies are needed to clarify the role of these biomarkers in the pathogenesis of retinal displacement.

Limitations

Our study has several limitations. First, the literature review lacks longitudinal studies, making it difficult to analyze cause-and-effect relationships between retinal displacement, retinal morphological features, and visual function. Second, studies were not standardized in terms of retinal displacement assessment methodology or the ethnic background of the groups, and some studies did not exclude vitreoretinal pathology of secondary etiology. Third, many studies assessing retinal displacement in patients with RRD did not include quantitative or semi-quantitative assessment, which may suggest subjectivity of the findings. Nevertheless, the presence of a large number of studies with similar results supports the reliability of the reported information.

Conclusions

Retinal and foveal displacement is an important part of the natural history of several congenital and acquired diseases, such as ROP, FEVR, and ERM, as well as a consequence of surgical intervention in ERM, RRD, and FTMH. In these conditions, it may be responsible for the severity of preoperative metamorphopsia, aniseikonia, or binocular diplopia or partially explain unsatisfactory surgical outcomes and therefore may be a useful point in medical counseling of patients with surgical retinal disorders.

Methods for assessing retinal displacement are based on evaluating changes in vessel position, as well as changes in vessel position and the foveal center relative to static markers—the optic disc and choroidal vessels. Although various imaging technologies may be used for this purpose, structural OCT, including en face mode, provides the most representative information, including precise identification of the foveal center.

Studying foveal displacement provides additional insight into the pathogenesis of these disorders, which may help in selecting the optimal treatment method and assessing expected functional outcomes. The severity of tangential neurosensory retinal deformation in patients with ERM and the basal diameter of an FTMH may predict the extent of postoperative retinal displacement and, consequently, the likelihood of persistent metamorphopsia. These factors suggest the use of specific surgical techniques, such as the inverted temporal ILM flap or reduced ILM peeling area, and favor less invasive approaches, including pneumatic retinopexy, and proper postoperative posture.

However, further studies are needed to develop robust and clinically applicable methods for displacement assessment, to analyze its association with other retinal biomarkers affecting visual function quality, and to expand the range of pathologies where it may play a role.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aes.amegroups.com/article/view/10.21037/aes-2026-0032/rc

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-2026-0032/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-2026-0032/coif). D.S.M. serves as an unpaid editorial board member of Annals of Eye Science from March 2025 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are 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.

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