treatment of breaks ioannis giannakis 5th sep 2007
TRANSCRIPT
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