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 degenerationwith 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