B

c

+

Fig. 54.4 The configuration of the RD and the expected location of the retinal break. (a) If the detachment is inferior and reaches only somewhat higher on one side of the disc, the break is likely to be found inferiorly, close to the center, on the side where the RD is higher. (b) If the detachment is mostly inferior and much higher on one side, the break is likely to be found superiorly on the high side. It is rare that the break is at the border of detachedÐattached retina; it is usually surrounded by detached retina completely22. (c) Occasionally the retina does not show a wide area of detachment and remains attached central to the break; the bilateral, inferior detachment has a Þngerlike, peripheral protrusion, pointing superiorly. This makes discovery of the break difÞcult and shows why the laser treatment must always be extended all the way to the ora serrata. D optic disc, M macula, B break (the area is shown by a black area with white dots). The red shows the attached, the blue the detached retina

54.2.4 Using Laser to Prevent RD Development

Treatment with laser is deÞned as sealing the edge of a retinal break. Prophylaxis is interpreted as lasering areas with a pathology that might in the future lead to RD or lasering retina that is healthy.21

21It must be mentioned that prevention via methods other than laser is also possible: prophylactic SB is rather commonly employed, and even PPV is occasionally performed, such as when cataract surgery is needed in a highly myopic patient (see Chap. 42).

22I.e., there is a small area of detached retina superior to the break.

54.2.4.1 Prophylaxis in the Affected Eye (RD, Current or Past)

¥The surgeon may elect to treat only the visible retinal lesion/s. The argument for this approach is that retinal breaks are detected in up to 20% of eyes with attached retina. Especially if the break remains asymptomatic, long-term follow-up proves that the risk of RD remains small.

ÐÒObservingÓ these patients after such focal treatment typically means a detailed fundus examination every 3 months. This is taxing for patient, ophthalmologist, and facility. It is also without any sound scientiÞc basis: why 3 months and not 2 or 5?23

ÐThe argument that a break does not necessarily justify treatment is false for another reason. In an eye that has, or has had, an RD, the risk of a future RD may be elevated if the VR traction has not been eliminated.

ÐMy preference is to always perform a 360¡ laser cerclage (see Sect. 30.3.3) during surgery, and I offer this option to each patient who presents with an attached retina but a history of RD. The presence or absence of a retinal tear does not inßuence this protocol since the RD often originates in an area that appeared healthy previously. This is the Þnal argument against the Òfocal laser onlyÓ type of prophylaxis (see below).

54.2.4.2 Prophylaxis in the Fellow Eye

If one eye had an RD and the fellow eye has the same risk for RD,24 it is akin to playing Russian roulette not to perform prophylactic laser in the fellow eye as well. My personal guidelines regarding prophylactic laser treatment are summarized in

Table 54.4.

Pearl

Unless the patient has a unilateral condition (such as pseudophakia, high myopia, trauma), the fellow eye has the same risk for RD development and should always be carefully examined. The patient needs to be informed about the risk, and the issue of prophylactic treatment (see Sect. 30.3.3) must be raised, detailing the risks and beneÞts.

54.2.4.3 The Patient with a History of a Retinal Tear (No RD)

My rationale is identical to that outlined above. Even in the absence of a history of an RD, a retinal tear signiÞes traction, and there is a risk of RD.25 Laser cerclage has a high enough success rate to more than offset its complication risk. I therefore offer the prophylaxis to the patient, but accept it if he declines the treatment Ð as long as he understands the implications. First, the focal treatment does

23See below for more details.

24Both are equally myopic; both are pseudophakic; both have the same vitreoretinal degeneration etc.

25Especially true if the tear is symptomatic.