Primary retinal detachments without apparent breaks.

In a prospective study of 415 consecutive eyes operated on for retinal detachment, there were no apparent retinal breaks in 41 eyes. Examination of the most likely site for breaks during, or shortly after, cryotherapy was helpful in detecting tiny breaks in several cases. All detachments without apparent breaks were operated on with a three-step operation: we applied two rows of confluent cryotherapy to all retinal breaks, drained subretinal fluid, and used buckles just anterior to the equator. Surgical cure, defined as reattachment for at least six months, was achieved in 93% of eyes with apparent breaks, and in 85% of eyes without apparent breaks. The latter figure increased to 91% when the seven patients with preoperative massive preretinal retraction were excluded.     

Management of rhegmatogenous retinal detachment without detectable breaks

Purpose: To evaluate the causes of failure to find retinal breaks, the anatomical and functional outcomes of patients with rhegmatogenous retinal detachment (RD) without detectable breaks (Group I), to compare the results with detectable breaks (Group II). Methods: Forty‐five out of 258 eyes that had RD without detectable breaks were analysed retrospectively. Results: The causes of failure to find retinal breaks were aphakia/pseudophakia in 22 eyes, small pupil without any eye disease in four eyes, corneal opacity in two eyes, cataract in two eyes, vitreous haze in two eyes, choroidal detachment in one eye, and unknown cause in 12 eyes. After a single scleral buckling procedure, anatomical re‐attachment of the retina successfully occurred in 62.2% of group I and 78.9% of group II patients. After repeated surgery, final anatomical success rates were 87.2% and 90.2%, respectively. The best corrected visual acuity was 6/60 or better in 53.9% in Group I and 52.5% in Group II. Conclusion: The main cause of failure to find the retinal break was aphakia or pseudophakia. Although the rates of retinal reattachment in eyes without detectable breaks in primary buckling surgery was lower than detectable breaks and reoperations were required more frequently, final success rates were satisfactory and similar in both groups.     

Risk stratifying retinal breaks

Objective

Argon laser retinopexy has been the primary treatment for retinal breaks for many decades. Prevention of progression to retinal detachment (RD) is the main objective. The benefit of laser retinopexy is well documented, although little has been reported on the risk factors for progression to RD. By addressing this issue, patients at high risk can be identified, and more timely specialist retinal input can be sought.

Methods

Data over a 6-month period from 45 consecutive patients undergoing laser retinopexy were reviewed. Patients were categorized into complete success (no more than 1 laser treatment), qualified success (no more than 3 laser or cryotherapy treatments), and treatment failure (more than 3 laser or cryotherapy treatments or progression to RD).

Results

Complete success was observed in 53.5% of patients, a further 34.9% of patients achieved a qualified success, and the remainder of the patients (11.6%) fell into the treatment failure category. About 9.3% of patients required cryotherapy, and 7.0% of patients underwent RD surgery. Patients with a bridging blood vessel and vitreous hemorrhage were significantly more likely to be in the treatment failure category than those without. RD was significantly associated with the presence of vitreous hemorrhage.

Conclusions

Patients with retinal breaks associated with bridging blood vessels and vitreous hemorrhage are at greater risk for poorer outcome. The area of subretinal fluid was not linked to failure. If complete laser of a tear is not possible or if concerns remain regarding treatment efficacy, prompt referral to a retina specialist for further management is recommended.     

Missed retinal breaks in rhegmatogenous retinal detachment

AIM: To evaluate the causes and associations of missed retinal breaks (MRBs) and posterior vitreous detachment (PVD) in patients with rhegmatogenous retinal detachment (RRD). METHODS: Case sheets of patients undergoing vitreo retinal surgery for RRD at a tertiary eye care centre were evaluated retrospectively. Out of the 378 records screened, 253 were included for analysis of MRBs and 191 patients were included for analysis of PVD, depending on the inclusion criteria. Features of RRD and retinal breaks noted on examination were compared to the status of MRBs and PVD detected during surgery for possible associations. RESULTS: Overall, 27% patients had MRBs. Retinal holes were commonly missed in patients with lattice degeneration while missed retinal tears were associated with presence of complete PVD. Patients operated for cataract surgery were significantly associated with MRBs (P=0.033) with the odds of missing a retinal break being 1.91 as compared to patients with natural lens. Advanced proliferative vitreo retinopathy (PVR) and retinal bullae were the most common reasons for missing a retinal break during examination. PVD was present in 52% of the cases and was wrongly assessed in 16%. Retinal bullae, pseudophakia/aphakia, myopia, and horse shoe retinal tears were strongly associated with presence of PVD. Traumatic RRDs were rarely associated with PVD. CONCLUSION: Pseudophakic patients, and patients with retinal bullae or advanced PVR should be carefully screened for MRBs. Though Weiss ring is a good indicator of PVD, it may still be over diagnosed in some cases. PVD is associated with retinal bullae and pseudophakia, and inversely with traumatic RRD.     

Full thickness macular breaks in rhegmatogenous retinal detachment with peripheral retinal breaks.

Between 1975 and 1989, 11 eyes were treated for retinal detachments with both peripheral and full thickness macular breaks. Long term retinal reattachment was dependent on successful closure of peripheral retinal breaks. Direct treatment of the macular break was necessary in only one case, which redetached 3 months after vitrectomy. Vitrectomy is not the initial treatment of choice for uncomplicated retinal detachments with both peripheral and full thickness macular breaks, unless required for the closure of the peripheral retinal breaks.     

Management of giant retinal breaks

A retrospective study involving 40 eyes of 40 patients with giant retinal break is presented. A comparison is attempted between cases where silicone oil is used and in cases where it was not used. The final success rate was found to be same in the two groups on long term follow-up.     

Prophylactic therapy of retinal breaks

Prophylaxis of selected retinal breaks is effective in preventing detachment. Most retinal breaks, however, will not cause detachment and can be safely followed without treatment. This paper reviews the evidence for and against prophylactic treatment of commonly encountered retinal breaks in an effort to arrive at typological guidelines for treatment. Education of patients with high risk of detachment is probably of equal value to cryotherapy or photocoagulation in preserving visual acuity.     

Peripheral retinal degenerations and breaks

One-hundred-three patients referred for evaluation of peripheral retinal lesions were reviewed; 56 eyes had peripheral degenerations without breaks, 62 eyes had atrophic holes, and 88 eyes presented retinal tears. Peripheral degenerations of the snail-track and typical lattice-like types occurred with reasonable uniformity throughout the periphery and were seen symmetrically in both eyes. Atrophic retinal holes frequently occurred within these degenerative areas. Peripheral degenerations with or without holes were often seen in young myopes and occurred mostly without giving rise to symptoms.Retinal tears occurred in older, predominantly hyperopic or emmetropic subjects, and usually presented with symptoms of acute entopsiae and/or photopsiae. The tears presented mainly in the upper temporal quadrants and were only associated with lattice degenerations of the ipsi or contralateral eye in one-third of cases. It was concluded that the population suffering from retinal tears only partially overlaps with that presenting with lattice degeneration of the retinal periphery, and that it is questionable if a causal link is present between these two conditions. As a result the raison d'être of prophylaxis can be called into question.

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Zusammenfassung Es wurden 103 Patienten (206 Augen) untersucht, die auf Grund von peripheren Fundusveränderungen überwiesen wurden. Das Patientengut wurde in 3 Gruppen aufgeteilt. Gruppe I bestand aus 28 Patienten mit peripherer Netzhautdegeneration ohne Lochbildung. In Gruppe II waren 31 Patienten mit Rundlöcher vertreten und Gruppe III beinhaltete 44 Patienten mit Hufeisenrissen. Periphere Schneckenspurendegeneration und typische palisadenartige Veränderungen traten, mehr oder weniger, regelmäßig über die ganze Peripherie verteilt auf und gaben sich symmetrisch in beiden Augen. Atrophische Rundlöcher erschienen am häufigsten in Degenerationsarealen. Periphere Degenerationen, mit oder ohne Löcher, waren häufiger bei jungen Myopen zu finden und verliefen meist asymptomatisch.Netzhautrisse waren bei älteren Individuen häufiger vorhanden und traten meist mit akuten Symptomen (Entopsien, Photopsien) auf. Hufeisenrisse waren am häufigsten in den temporal oberen Quadranten zu finden. Nur ein Drittel der Patienten mit Netzhautrissen hatten auch eine periphere Degeneration, sei es am betroffenen oder am kontralateralen Auge. Schlußfolgerung dieser Untersuchung ist, daß die Bevölkerung mit Netzhautrissen nur sehr unvollständig mit den an Netzhautdegenerationen leidenden Patienten übereinstimmt, sodaß ein kausaler Zusammenhang nur bedingt vertreten werden kann und die gängigen prophylaktischen Abriegelungsindikationen überdacht werden sollten.

     

Retreatment of retinal breaks using a thin cryoprobe without displacement of the scleral buckle

A thin (20-gauge) cryoprobe can be used to retreat retinal breaks without disturbing a previous scleral buckle. The fibrous sheath covering the episcleral exoplant is incised at its anterior margin, and the 20-gauge probe is introduced between the exoplant and the sclera. Angling the tip slightly permits precise treatment around the retinal break, without removing and replacing the scleral sutures securing the exoplant.