Purpose To investigate the relationship between metamorphopsia and macular morphologic changes after successful repair of rhegmatogenous retinal detachment (RD). Design Prospective, interventional, consecutive study. Methods The study included 129 eyes of 129 patients who had undergone successful retinal reattachment surgery. The severity of metamorphopsia was recorded using M-CHARTS and foveal microstructure was assessed with spectral-domain optical coherence tomography (OCT) at 6-12 months postoperatively. Results The mean metamorphopsia score was 0.30 ± 0.46, and 50 of 129 patients (39%) had metamorphopsia. Metamorphopsia was more severe in eyes with macula-off rhegmatogenous RD than those with macula-on ( P  < .001). Eighteen of 50 eyes with metamorphopsia exhibited abnormal structures in the macular region (epiretinal membrane, disruption of the photoreceptor inner and outer segment junction, cystoid macular edema, macular hole, or subretinal fluid), whereas the other 32 eyes showed no morphologic changes with OCT. In these 32 eyes, the horizontal metamorphopsia score (0.86 ± 0.50) was significantly higher than the vertical metamorphopsia score (0.62 ± 0.39, P < .05). Nine of 69 eyes with preoperative macula-on rhegmatogenous RD developed postoperative metamorphopsia. Of the 9 eyes, 6 showed abnormal macular structures and the other 3 had normal-appearing OCT. The macula briefly detached during vitrectomy in these 3 cases. Conclusions In eyes that remained macula-on throughout surgery and had normal-appearing OCT, metamorphopsia did not develop. In some cases, the reason for metamorphopsia was anatomically obvious. In other cases that were preoperative and intraoperative macula-off, postoperative retinal vertical displacement could cause predominantly horizontal metamorphopsia.