Conclusion

Retinal breaks. whether atrophic

retinal holes,

oper-

culated retinal holes. retinal dialyses,

or retinal

tears

with a flap

under vitreous

traction

(horseshoe

tears).

may be associated

with

retinal detachments.

Under

certain circumstances.

the ophthalmologist

may

wish to treat

these breaks

prophylactically to reduce

the chances

of the development

of a clinical

retinal

detachment.

There are

five major

steps in this

process.

l. Detection

of the

retinal break(s)

2. Making

a treatment decision

3. Selection

of treatment

modality

4. Treatment

of the retinal.breakrs)

5. Follow-up of treatment

Detection

of Retinal Break(s)

The

vast majority of retinal

breaks are asymptomatic.

They

are

discovered

on routine examination

of

the

pe~ipheral

retina by

indirect ophthalmoscopy

or

by

slit lamp

biomicroscopic

examination either

using

a contact

lens with

angled

mirrors (such as a Gold-

mann 3-mirror

lens) or a noncontact

lens

(such

as a

78- or 90-diopter

lens). Although

the prevalence

of

retinal breaks has

been

reported to

lie between

4%

and 18%,

it is generally

accepted

that

the preva-

lence of asymptomatic

retinal

breaks in the general

population

is approximately

6%.1

Certain patients,

although

asymptomatic,

should

be considered

at

higher risk for

retinal breaks

and

should

be exam-

ined with

a higher index of suspicion. This

includes

patients

with a history of retinal detachment

in me

ment; high myopia;

disorders associated

with vitre-

oretinal

traction

and retinal

detachment

such as

lattice degeneration

and Stickler's

syndrome;

aphakia;

or pseudophakia

with

anterior segment vit-

reous adhesions

or

incarceration.

Symptomatic retinal

breaks

are much

less com-

mon than

asymptomatic

ones.

They are

generally

associated

with spontaneous

detachment

(separa-

tion) of the posterior

vitreous.

This detachment

and

subsequent

anterior

migration

of the

posterior

bor-

vitreoretinal

adhesion.

resulting

in tearing

of the

retina. Such tears

become symptomatic

when

they

are accompanied

by light flashes

(photopsia)

or the

sudden

appearance

of new floaters.

These

floaters

(which

may represent

pigmented

cells,

red

blood

cells,

or

posterior

vitreous

condensation)

are

described

by the

patient as "spots,"

or

(if they are

more numerous)

"lines" or

"clouds."

A posterior

vitreous

condensation

may

also

be

described

as a

only once or may occur

repeatedly

over

a period of

days or weeks. Although

these photopsia

are

gener-

ally noticed

in the temporal

visual

field,

this

has no

value for localizing

the

retinal break.

Every patient with the

sudden

onset

of photop-

sia and/or

floaters does

not necessarily

have

a reti-

nal break.

However, all

such patients

(unless they

are known

to have

an

unrelated

disease causing

24

MANUAL

OF RETINAL

SURGERY

these symptoms)

deserve

a careful

examination

to

determine

if

a break

is present.

Although

vitreous

hemorrhage

may

accompany

a posterior

vitreous

detachment

unassociated

with

a retinal

break,

the

finding

of

red blood

cells

or frank vitreous

hemor-

rhage should particularly

alert the examiner

to the

possibility

of a retinal

break

..Finding

pigment

cells

in the vitreous

is

also highly

associated

with

the

possibility

of a coexisting

retinal break.

Indirect ophthalmoscopy

with scleral indentation

(also known

as scleral

depression)

remains

the most

valuable method

of finding

retinal breaks.

Although

many breaks can

be discovered

without

the

use

of

scleral indentation,

tiny

breaks,

anteriorly

located

breaks,

atrophic

breaks,

and breaks

in highly

myopic

or lightly

pigmented

eyes

may

be

easily

overlooked

if scleral

indentation

is not performed.

Scleral indentation

also

permits more

accurate

determination

of

the presence

and

amount

of

sub-

retinal

fluid surrounding

a break.

Most comprehensive

ophthalmologists

do not

use biornicroscopic

examination

of

the

peripheral

retina

on

a routine

basis.

However, biomicroscopic

examination

of the

peripheral

retina

using

a contact

or noncontact

lens can be valuable

when

a break

is

suspected

but not

clearly

visualized

by indirect

oph-

thalmoscopy

with

scleral

depression.

(A noncontact

lens is preferred

by

many

retina subspccialists

over

a contact

lens,

as

it avoids

the

use

of

contact

lubri-

cants

that

can

make

subsequent

indirect

ophthal-

moscopy

difficult.)

If a small.

difficult

to

visualize retinal

break

is

discovered.

the examiner

should

take

careful

note

of the location

of

the break

in relation

to other

more

easily visualized

fundus landmarks

such as chorioreti-

nal

scars.

retinal

vessels.

VOJ1ex veins

and

ampul-

Iae, and others.

This

will greatly

facilitate

localizing

the

break

during

later

treatment.

Decisions

Regarding

Treatment:

Is Treatment

Necessary?

If a retinal

break

is discovered

on

indirect

ophthal-

moscopy or biornicroscopic

examination,

the patient

must be informed

of the

findings, their

significance,

.and the management

options.

Only

then

can an

appropriate management

decision

be

reached. As

will be noted

below,

a decision

to treat or not to treat

is sometimes

quite

obvious

to

the

ophthalmologist

and is supported

by

statistically

valid data.

In most

situations,

however,

data

do

not

currently

exist to

clearly direct a

management

decision. Available

incomplete

data and

the risks

and

benefits

of thera-

peutic

options

must

be presented

to the patient.

In

the hands

of an experienced

surgeon, the

treatment

of retinal

breaks

should

be

associated with

a very,

very low

incidence of complications.

However,

this

infrequency

of complications

should not

be trans-

lated into a rationale

to treat

all breaks. Treatment

of

most asymptomatic

retinal

breaks

Is not

substanti-

ated by available

prospective

data. Therefore,

while

treatment

may

carry

a very

low frequency

of com-

plications,

it can

be

associated

wirh discomfort

and

substantial

cost, and

may be ultimately

unnecessary.

If most

retinal

breaks

led

to

retinal detachment,

the relative

incidence

of breaks

would be

similar to

that of retinal

detachment.

The

incidence

of clinical

retinal detachment

(0.01-0.02%)

is much lower

than

that for the discovery

of

retinal

breaks.

Byer,

in a

long-term prospective

follow-up

of

235

eyes with

asymptomatic

retinal

breaks

(including

46 eyes

with

traction retinal tears). detected

no subsequent

clini-

cal retinal detachment

from

the nontrcatcd

rears."

Even the treatment

of lesions

in certain

groups

of "high-risk"

eyes

has

not

been statistically

vali-

dated.

A large

prospective

trial

treating vitrcorctinal

pathology

in

fellow

eyes

of

retinal detachment

patients

in Israel

concluded

that treatment

conferred

no significant

benefit;'

Yet

another study observed

that it is not preexisting

pathology

that causes

sub-

sequent retinal

detachments,

but new

breaks

in

retina previously

felt

to be normal."

How does the ophthalmologist

determine

which

breaks

require

treatment?

Certain criteria-some

"hard"

and some

"soft"--ean

assist

in making

this

clinical

judgment.

The presence or

absence

of

associated symptoms

(photopsia and/or new

floaters within-several

weeks

of

examination)

is the most

important determinant

of

risk. In one

series,

symptomatic

breaks

were

associated with

subsequent

clinical

retinal

detach-

ment formation

in about

30% of cases.~

Therefore,

any break associated

with fresh symptoms

of

pho-

topsia and/or floaters

should

be strongly

considered

for

treatment.

The

risk

associated

with

the various

types of

asymptomatic

breaks

has not

been

well

quanti-

fied. In

his series,

Mer in et al. discovered

that

19%

of

fe llow

eyes

had retinal

breaks,

15% of

which later developed

retinal

detachments."

Of

those detachments,

71 % came

from flap

(or

"horseshoe")

tears

and

only

19% of

the

breaks

were tears.

Tract

io na l retinal

rears,

as noted

above.

are

more

frequently

assoc

iated

with symptoms

and

are therefore

of more clinical

significance.

How-

ever.

it

is

not

uncommon

to

find tractional

tears

that,

by virtue

of

their

appearance

and

associated

pigment

epithelial

reaction,

have clearly

been

present

for months

if

not years.

Therefore.

asymptomatic

tractional

tears

themselves

do not

necessarily

confer

a poor

prognosis.

As

noted

above. Byer

evaluated

50 tractional

tears

for up

to

IR years

without

tre atrnerit

and

without

any

subsequent

retina!

detachment.

Although

the

strongest

data

favoring

treatment

of

horseshoe

tears are

for symptomatic

tears,

some

ophthal-

mologists

believe that

all tractional

tears should

be

treated.

Others

believe

that the

treatment

deci-

sion should

be

made

on