Prophylactic Treatment of Retinal Breaks
Any retinal break can cause a retinal detachment by allowing liquid from the vitreous cavity to pass through the break and separate the sensory retina from the RPE. However, the vast majority of retinal holes or breaks do not cause a detachment.
The ophthalmologist may consider prophylactic treatment of breaks in an attempt to reduce the risk of retinal detachment (Table 16-1). Treatment does not eliminate the risk of new tears or detachment.
The goal of prophylactic laser treatment or cryotherapy of retinal breaks is the creation of a chorioretinal adhesion around each break to prevent fluid from entering the subretinal space (Fig 16-12). If subretinal fluid is present, treatment is applied so it surrounds the area of subretinal fluid. If insufficient treatment is applied, vitreous traction can lead to anterior extension of horseshoe tears and retinal detachment. Similarly, when treating lattice degeneration, the entire lesion needs to be surrounded with treatment applications.
In considering prophylaxis, the ophthalmologist weighs numerous factors, including symptoms, family history, residual traction, size and location of the break, phakic status, refractive error, status of the fellow eye, presence of subretinal fluid, and availability of the patient for follow-up evaluation. Prophylaxis is sometimes contraindicated in eyes with more than 6.00 diopters (D) of myopia and more than 6 clock-hours of lattice degeneration. The following discussion serves only as a broad guideline, because many clinical factors should be considered in each patient. (Also see the discussion of hereditary hyaloideoretinopathies with optically empty vitreous in Chapter 17.)
Table 16-1 Prophylactic Treatment of Retinal Breaks
Figure 16-12 Widefield image shows a retinal tear inadequately surrounded by laser and subsequent retinal detachment.
(Courtesy of Stephen J. Kim, MD.)
Symptomatic Retinal Breaks
Overall, 7%–18% of eyes with a symptomatic PVD are found to have 1 or more tractional tears at the time of the initial examination. Numerous clinical studies have demonstrated that acute, symptomatic breaks are at greater risk of progressing to retinal detachment, especially if there is associated vitreous hemorrhage. Therefore, acute symptomatic flap tears are commonly treated prophylactically.
Acute operculated holes are less likely to cause detachment because there is no residual traction on the adjacent retina, and they usually are not treated. However, if slit-lamp biomicroscopy reveals persistent vitreous traction at the margin of an operculated hole, if the hole is large or located superiorly, or if there is vitreous hemorrhage, prophylaxis should be considered.
Atrophic holes are often incidental findings in a patient who presents with an acute PVD. Generally, treatment is not recommended for these holes.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.