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