Primary Retinal Detachment

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30 2 Prophylaxis in Fellow Eye of Primary Retinal Detachment degeneration, senile retinoschisis, retinal breaks, and cystic retinal tufts also have a significant prevalence rate in primary eyes. Here, also the natural histories as well as the futility of applying so-called “prophylactic” treatment has been amply documented [23–26]. In summary, we may say that the well-established practice of applying “prophylactic” treatment to visible predisposing peripheral retinal lesions, whether in primary eyes or in fellow eyes, before any detachment has occurred, and specifically for the purpose of preventing this outcome has by now been thoroughly discredited and must be discarded as the “standard of care”. This answers the first major question of this chapter, and constitutes, “What NOT to do”. This does not mean however that retinal detachments cannot be prevented. However, our clinical attention must be directed to a completely different matter.We should not treat asymptomatic eyes (whether primary or fellow eyes), but we should be on the lookout for patients who complain of recent visual symptoms that suggest the occurrence of a posterior vitreous detachment. Such symptoms consist of the sudden appearance of vitreous floaters or light flashes. It has been reported that among patients older than 50 years of age, the symptom of suddenly appearing floaters is known to be caused by posterior vitreous detachment in 95% of cases [27]. Patients with this complaint all should be thoroughly and conscientiously examined with indirect ophthalmoscopy and simultaneous scleral indentation in both eyes, to search for any new tractional retinal tear or tears that may be present. If such are discovered they should be promptly treated by surrounding them with either laser photocoagulation or cryotherapy. It has been found in several clinical series [14, 28–31] and in an autopsy series by Foos [32] that about 15% of eyes that have had a vitreous detachment also have a tractional retinal tear or tears. It has been reported that around 28% of these will progress to a retinal detachment before the patient first consults an ophthalmologist [33]. If the remaining 72% of eyes with fresh retinal tears are not promptly discovered and treated, about one-third of this number
2 Prophylaxis in Fellow Eye of Primary Retinal Detachment 31 will progress to a retinal detachment either very soon or within 2–3 months. Among eyes discovered with fresh tractional retinal tears but which have not yet led to retinal detachment, it has been well established that about 35% will lead to retinal detachment [34–36]. Therefore, prompt examination of patients with suggestive symptoms of vitreous detachment, followed by prompt treatment of any new tractional retinal tears, is mandatory and will provide a high probability of preventing further progress to a retinal detachment, which is a much more serious event. Altogether these account for approximately 95% of all retinal detachments. If all fresh retinal tears resulting from posterior vitreous detachment were discovered at the time when no retinal detachment was yet present, and were successfully treated at that time, then approximately 44% of retinal detachment in general could be prevented (Table 2.4). We must remember that about two-thirds of the eyes with such tears would never progress to detachment even without treatment. Herein lies a very great opportunity for the successful prevention of this historic and continuing scourge of vision. It may be thought that eyes that undergo a sudden posterior vitreous detachment may have a still higher risk if they contain pre-existing visible predisposing lesions related to retinal detachment. However, in a large prospective study of such eyes [14] it was Table 2.4. Fate of new retinal tears resulting from posterior vitreous detachment Progressing promptly to retinal detachment 28% (before consulting ophthalmologist) Expected to progress to detachment 24% (without treatment) = 72/3 Total progressing to retinal detachment 52% (without treatment) Proportion of retinal detachments prevented (in general) 44%
Page 2 and 3: Ingrid Kreissig (Ed.) Primary Retin
Page 4 and 5: Professor Dr. med. Ingrid Kreissig
Page 6 and 7: Contents 1 The History of Retinal D
Page 8 and 9: List of Contributors Gary W. Abrams
Page 10 and 11: List of Contributors XI Hermann D.
Page 12 and 13: 2 Helmholz in 1850 made an accurate
Page 14 and 15: 4 (vitreous, gelatin) into the ante
Page 16 and 17: 6 with scleral resection that set t
Page 18 and 19: 8 ditis [72-74].Temperatures up to
Page 20 and 21: 10 1 The History of Retinal Detachm
Page 26 and 27: 16 ion [147]. Perfluorocarbon liqui
Page 36 and 37: 26 2 Prophylaxis in Fellow Eye of P
Page 42 and 43: 32 found that eyes with pre-existin
Page 46 and 47: 36 3 Encircling Operation with Drai
Page 64 and 65: Chapter 4 Pneumatic Retinopexy for
Page 66 and 67: Technique 57 Case Selection Proper
Page 68 and 69: Technique 59 Table 4.1. Gas charact
Page 70 and 71: Technique 61 solution; however,thes
Page 72 and 73: Technique 63 gas reflux. Following
Page 74 and 75: Complications: Prevention and Manag
Page 76 and 77: New Possibilities 67 ing on type an
Page 78 and 79: Results 69 Table 4.7 (continued) Au
Page 80 and 81: Discussion 71 surgical failures. Fa
Page 82 and 83: Discussion 73 Disadvantages of PR A
Page 84 and 85: References 75 situations, then to p
Page 86 and 87: References 77 24. Tornambe PE, Hilt
Page 88 and 89: References 79 51. Pournaras CJ, Don
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Chapter 5 Vitrectomy for the Primar
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Indications 83 Table 5.1. Indicatio
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Indications 85 Fig. 5.2. The vitreo
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Surgical Technique 87 vitrectomy an
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Outcomes 89 will be visible under a
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Outcomes 91 almost no persistent su
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References 93 7. Heimann H, Bornfel
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96 6 Minimal Segmental Buckling Wit
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98 6 Minimal Segmental Buckling Wit
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100 the operating table with the re
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102 6 Minimal Segmental Buckling Wi
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106 a b 6 Minimal Segmental Bucklin
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114 a 6 Minimal Segmental Buckling
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122 c d 6 Minimal Segmental Bucklin
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124 c Fig. 6.14c 6 Minimal Segmenta
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Table 6.1. Preoperative characteris
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Table 6.3. Final attachment after m
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130 Choroidals In 4 of the 1,462 de
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Table 6.4. Visual acuity at 2 years
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140 Probably, the future question n
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146 7 Pharmacological Approaches to
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152 heparin was published in eyes u
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154 search for compounds with hepar
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Chapter 8 Systematic Review of Effi
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Materials and Methods 163 Table 8.2
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Discussion 165 30% 25% 20% 15% 10%
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Discussion 167 Fig. 8.2. The small
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Conclusion 169 vitrectomy and searc
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References 171 8. Brazitikos PD, D
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References 173 34. Gunduz K, Gunalp
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References 175 63. Schepens CL (195
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178 9 Repair of Primary Retinal Det
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180 a b Fig. 9.3a,b. Legend see pag
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186 a b 9 Repair of Primary Retinal
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188 might eliminate traction on the
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Chapter 10 Retinal Detachment Repai
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Retinal Detachment Repair: Outlook
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References 207 It is impossible to
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210 C Campbell 7 case selection 57,
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212 M Machemer 13 macular - complic
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214 retinal - detachment - - bilate
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