Treatment of breaks

Ioannis Giannakis

5th Sep 2007

Treatment of retinal breaks

Prophylactic laser treatment of peripheral retinal lesions to prevent retinal detachment enjoys widespread use

However, clinical and scientific evidence for such treatment only exists for a few particular clinical situations

Aylward: Retina, May 2007

Case 1 61 old high myopic patient(-12)referred for preop

exam before cataract surgery Fundus: round hole with free floating operculum at 9

o’clock. No SRF. PVD(+). Brother had RD & patient is lawyer Laser advocated for the asymptomatic retinal hole

with operuculum by 55% BEAVRS, 40%SRS, 84%GRS

Davis-1973: The natural history of breaks without RD is 0-0,8%, so why high rate of proposed Laser?

Case 2 69 years old pseudophakic: a few floaters but no

flashing lights with sudden onset 2 months ago. No recent change in symptoms. No family history of RD

Fundus: Small U-tear at 10 oclock. No SRF. PVD(+). Laser was the choice for this symptomatic retinal tear

by 87%BEAVRS, 90%SRS, 85%GRS. Cyo+Buckle, by 4%BEAVRS, 1%GRS Byer-1994: symptomatic U-tears, lead to RD in >50%

of cases, if it is <3/12 old and left untreated

Case 3 22 years old myopic(3,5) urgently referred by optician Fundus: 2 atrophic holes at equator, at 10 o clock,

inside large areas of lattice. No SRF. No PVD. No family history of RD, and plans to leave in 2weeks

for a 3month overland trip through Africa Laser by 25%BEAVRS, 20%SRS, 52%GRS Byer-1998: What happens to untreated asymptomatic

breaks, and are they affected by PVD? Lattice with atrophic holes, in the above paper of 150

patients, lead to clinical RD in only 2% of cases

Case 4 Self-referral of 31 years old businessman from Middle

East with Myopia of 6,5. Asymptomatic and wants 2nd opinion

Fundus: small dialysis at 4 oclock, extending >0,5 clock hours, with small cuff of SRF, and pigmented demarcation line. No PVD, No family history of RD

BEAVRS=24%laser, 24%cryobuckle, 50%observe SRS and GRS= 50%laser, 10%buckle, rest observe No general agreement found in literature

Case 5 77 years old myopic(-3) referred for routine exam by the GP.

Floaters in OD with vague date of onset(1-2months). No recent change in symptoms. Had a succesful RD repair in the fellow eye 2years ago

Fundus:Lattice over 2clock hours at equator, probable PVD and leaving for a 3week cruise next week

Laser for the asymptomatic? Fellow eye with lattice after RD of the other eye, was recommended by 46%BEAVRS, 20%SRS, 55%GRS

Folk-1989: 388 consecutive patients with lattice and history of RD in the fellow eye, 7years FU, RD would be prevented in only 3 eyes for every 100 treated patients

Case 6 Self-referral 42 years old myopic -5, for 2nd

opinion. Had a spontaneous non-traumatic GRT 3,5 clock

hours with RD 2months ago successfully treated with vity-endolaser

??Prophylactic treatment to fellow eye 360 Laser by 52%BEAVRS, 10%SRS, 15%GRS Aylward-2003:Spontaneous GRT lead to retinal

breaks in 50% of cases, and RD occurs to 32%..Prophylactic 360Rx reduces risk but GRS not familiar with this practise

Why treat? Patients presenting with lesions which predispose

to a rhegmatogenous RD form a significant percentage of ophthalmic practice

15% of symptomatic PVD have tears Asymptomatic breaks occur in 7% of patients over

the age of 40 Lattice is present in 8% of general population and

30% of RD have lattice related tears About 1% of patients undergoing cataract surgery

will develop a RD:Wilkinson-Ophth-2000

Why treat? The evidence base A prospective randomised clinical trial is

lacking in this contoversial area of management

Strong Risk factors: Severity of Myopia, Presence of PVD, History of RD in the fellow eye-trauma-previous cataract surgery

Despite preventive prophylactic Rx, the risk of RD appears to persist

What to treat?

The pathogensis of a rhegmatogenous RD includes Vitreous syneresis followed by PVD, resulting in Vitreoretinal traction, and RD

Horseshoe-shaped Tears have persistent vitreoretinal traction, and if left untreated cause RD in 33-55% of cases, so Rx always is indicated, immediately adjacent to localized SRF

Asymptomatic patients with Lattice degeneration-with or without retinal holes is not a indication for laser, but might be considered in the fellow eye of very high risk patients or if myopia is<-6 and lattice is<6hours extension

How to treat? Surround the break & any

SRF with thermal burns The burn becomes an

adhesion between retina & RPE, and this limits potential flow of fluid from the vitreous cavity through a break

Cryo may take up to 3weeks for an effective adhesion

Summary of Treatment Complications: RD may occur despite

adequate treatment of breaks, New breaks due to excessive retina damage, ERM

The genuine value for treating all vitreoretinal lesions remains unknown, due to the retrospective nature of most studies

Education of patients is more important, than treating everything