- Email: [email protected]
Invited commentary: for treatment
Wilkinson 䡠 Prophylaxis 7. Verdaguer J, Vaisman M. Treatment of symptomatic retinal breaks. Am J Ophthalmol 1979;87:783– 8. (II) 8. Pollak A, Oliver M. Argon laser photocoagulation of symptomatic flap tears and retinal breaks of fellow eyes. Br J Ophthalmol 1981;65:469 –72. (II) 9. Colyear BH Jr, Pischel DK. Preventive treatment of retinal detachment by means of light coagulation. Trans Pac Coast Otoophthalmol Soc 1960;41:193–217. (II) 10. Byer NE. Long-term natural history of lattice degeneration of the retina. Ophthalmology 1989;96:1396 – 402. (II) 11. Folk JC, Arrindell EL, Klugman MR. The fellow eye of
patients with phakic lattice retinal detachment. Ophthalmology 1989;96:72–9. (II) 12. Benson WE, Grand MG, Okun E. Aphakic retinal detachment. Management of the fellow eye. Arch Ophthalmol 1975;93: 245–9. (II) 13. Hovland KR. Vitreous findings in fellow eyes of aphakic retinal detachment. Am J Ophthalmol 1978;86:350 –3. (II) 14. Byer NE. Rethinking prophylactic therapy of retinal detachment. In: Stirpe, M, ed, Advances in Vitreoretinal Surgery. New York: Ophthalmic Communications Society 1992;399 – 411. (II)
Invited Commentary: For Treatment The evidence-based approach to medicine is a very desirable evolving tool for clinical care. We are still learning how to use it effectively. when combined with a careful evaluation of the patient’s history, findings on examination, and psychosocial and economic status, it adds greatly to the integrity of a physician’s recommendations for management. The paucity of the A:I prospective prevention studies of retinal tears and lattice degeneration reinforces the need for thoughtful, caring, competent, and artfully individualized medicine, especially in the asymptomatic patient. The creation of the rating systems of Importance to Care and Strength of Evidence is a brilliant innovation for focusing on current reality. I believe my care has improved over the years directly as a result of Dr. Byer’s work, but we differ on some important details. My management principles are strongly influenced by 32 years of careful preoperative drawing for all scleral buckles. These record the details of the retina, alterations of the retinal pigment epithelium, and the location of nearly every hole in over 1500 detachments. Many patients demonstrated subtle but definite evidence of causative asymptomatic flap tears with either demarcation lines, retinal thinning from long standing subclinical retinal detachments, or both. These eventually had extended and become symptomatic. Some of these tears were exquisitely small and could be confirmed only by a diathermy mark. It is unreasonable to expect a patient to perceive and report, or to remember and lateralize accurately the symptoms of new floaters in every instance. Because the risks of prophylactic laser are so slight and my experience with untreated and asymptomatic detachment causing lesions is so extensive, I choose to treat all tears that have definite residual focal traction. As soon as the treatment heals, the patient is essentially at prelesion status and does not need special or even regular retinal follow up. The marks are 500 mu, 0.2 second, creamy white and tangent to each other. I prefer the slit lamp with a three mirror lens for laser delivery, although anterior marks may require the indirect laser or an Eisner cone for indentation. Two or From the Lions Eye Institute, Albany Medical College, Albany, New York Address correspondence to Dr. G.S. Ray Lions Eye Institute, Albany Medical College, 35 Hackett Boulevard, Albany, NY 12208
three rows of laser marks are placed posteriorly and laterally, increasing to three or four at the lateral horns, and five or six anteriorly (or to the ora). Occasionally cryo is needed. I always leave at least 1⁄2 cryo width of normal retina between the freeze and the hole. Cryo breaks down the RPF pump effect for 3–5 days. A number of retinal detachments are caused by old nondetectable traumatic tears of the pars plana, as evidenced by a detachment, multiple demarcation lines, and a focally detached ora. These were cured by a localized anterior buckle placed where the ora was abnormal or “funny looking.” Armed with this experience, I prophylactically treat every case where I find a “funny ora” after trauma and, of course, treat any asymptomatic dialysis. Two or three rows of laser, again tangential to each other, are delivered to make a new ora posterior to any abnormality, and extend 1⁄2 clock hour at the ends to connect with normal ora. Cryo is used only when laser is not feasible, and 1⁄2 cryo mark of untreated retina is left between the marks. The treatment also connects with the ora at the ends of the lesion and behind adjacent normal ora. I almost never treat any fully operculated tears, unless the patient is at high risk for other reasons and there is definite proximal vitreous traction proven with a three-mirror contact lens. I infrequently treat lattice in a fellow eye, regardless of lens status, and then only after a careful examination demonstrates residual vitreous traction on the lesions and the symptomatic eye had a detachment related to lattice with a horseshoe tear. Large areas of treatment are avoided. However, I will treat a similar fellow eye prophylactically 6 to 8 weeks before cataract removal. The ends of the lattice are treated with a C-shaped laser distribution as if treating a horseshoe tear, but not treating the lattice itself. For all other asymptomatic eyes with lattice, with or without atrophic holes, and eyes with isolated atrophic holes, I prefer to re-examine in 12 to 18 months and to give the patient clear instructions regarding the sudden onset of new floaters as a signal to have a complete indirect retinal exam within 48 hours. An explanation of the pathologic condition sensitizes the patient to become an effective partner in the management of all asymptomatic cases.
G. STEWART RAY, MD Albany, New York
Invited Commentary: Against Treatment Dr. Wilkinson’s report discusses perceived deficiencies that have become evident in searching the literature pertaining to prophylactic treatment of asymptomatic retinal breaks and lattice degen-
Address correspondence to Norman E. Byer, MD, 3400 West Lomita Boulevard, Suite 200, Torrance, CA 90505.
eration. This kind of systematic effort is highly laudable and is a long overdue development in ophthalmology. There is a remarkable and painful realization that over a period of more than 40 years, since the beginning of the worldwide popularization of so-called “prophylactic” treatment to prevent retinal detachment, there has been relatively little progress in understanding or change in attitudes about this subject. Although the PPP panel must be
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patients with phakic lattice retinal detachment. Ophthalmology 1989;96:72–9. (II) 12. Benson WE, Grand MG, Okun E. Aphakic retinal detachment. Management of the fellow eye. Arch Ophthalmol 1975;93: 245–9. (II) 13. Hovland KR. Vitreous findings in fellow eyes of aphakic retinal detachment. Am J Ophthalmol 1978;86:350 –3. (II) 14. Byer NE. Rethinking prophylactic therapy of retinal detachment. In: Stirpe, M, ed, Advances in Vitreoretinal Surgery. New York: Ophthalmic Communications Society 1992;399 – 411. (II)
Invited Commentary: For Treatment The evidence-based approach to medicine is a very desirable evolving tool for clinical care. We are still learning how to use it effectively. when combined with a careful evaluation of the patient’s history, findings on examination, and psychosocial and economic status, it adds greatly to the integrity of a physician’s recommendations for management. The paucity of the A:I prospective prevention studies of retinal tears and lattice degeneration reinforces the need for thoughtful, caring, competent, and artfully individualized medicine, especially in the asymptomatic patient. The creation of the rating systems of Importance to Care and Strength of Evidence is a brilliant innovation for focusing on current reality. I believe my care has improved over the years directly as a result of Dr. Byer’s work, but we differ on some important details. My management principles are strongly influenced by 32 years of careful preoperative drawing for all scleral buckles. These record the details of the retina, alterations of the retinal pigment epithelium, and the location of nearly every hole in over 1500 detachments. Many patients demonstrated subtle but definite evidence of causative asymptomatic flap tears with either demarcation lines, retinal thinning from long standing subclinical retinal detachments, or both. These eventually had extended and become symptomatic. Some of these tears were exquisitely small and could be confirmed only by a diathermy mark. It is unreasonable to expect a patient to perceive and report, or to remember and lateralize accurately the symptoms of new floaters in every instance. Because the risks of prophylactic laser are so slight and my experience with untreated and asymptomatic detachment causing lesions is so extensive, I choose to treat all tears that have definite residual focal traction. As soon as the treatment heals, the patient is essentially at prelesion status and does not need special or even regular retinal follow up. The marks are 500 mu, 0.2 second, creamy white and tangent to each other. I prefer the slit lamp with a three mirror lens for laser delivery, although anterior marks may require the indirect laser or an Eisner cone for indentation. Two or From the Lions Eye Institute, Albany Medical College, Albany, New York Address correspondence to Dr. G.S. Ray Lions Eye Institute, Albany Medical College, 35 Hackett Boulevard, Albany, NY 12208
three rows of laser marks are placed posteriorly and laterally, increasing to three or four at the lateral horns, and five or six anteriorly (or to the ora). Occasionally cryo is needed. I always leave at least 1⁄2 cryo width of normal retina between the freeze and the hole. Cryo breaks down the RPF pump effect for 3–5 days. A number of retinal detachments are caused by old nondetectable traumatic tears of the pars plana, as evidenced by a detachment, multiple demarcation lines, and a focally detached ora. These were cured by a localized anterior buckle placed where the ora was abnormal or “funny looking.” Armed with this experience, I prophylactically treat every case where I find a “funny ora” after trauma and, of course, treat any asymptomatic dialysis. Two or three rows of laser, again tangential to each other, are delivered to make a new ora posterior to any abnormality, and extend 1⁄2 clock hour at the ends to connect with normal ora. Cryo is used only when laser is not feasible, and 1⁄2 cryo mark of untreated retina is left between the marks. The treatment also connects with the ora at the ends of the lesion and behind adjacent normal ora. I almost never treat any fully operculated tears, unless the patient is at high risk for other reasons and there is definite proximal vitreous traction proven with a three-mirror contact lens. I infrequently treat lattice in a fellow eye, regardless of lens status, and then only after a careful examination demonstrates residual vitreous traction on the lesions and the symptomatic eye had a detachment related to lattice with a horseshoe tear. Large areas of treatment are avoided. However, I will treat a similar fellow eye prophylactically 6 to 8 weeks before cataract removal. The ends of the lattice are treated with a C-shaped laser distribution as if treating a horseshoe tear, but not treating the lattice itself. For all other asymptomatic eyes with lattice, with or without atrophic holes, and eyes with isolated atrophic holes, I prefer to re-examine in 12 to 18 months and to give the patient clear instructions regarding the sudden onset of new floaters as a signal to have a complete indirect retinal exam within 48 hours. An explanation of the pathologic condition sensitizes the patient to become an effective partner in the management of all asymptomatic cases.
G. STEWART RAY, MD Albany, New York
Invited Commentary: Against Treatment Dr. Wilkinson’s report discusses perceived deficiencies that have become evident in searching the literature pertaining to prophylactic treatment of asymptomatic retinal breaks and lattice degen-
Address correspondence to Norman E. Byer, MD, 3400 West Lomita Boulevard, Suite 200, Torrance, CA 90505.
eration. This kind of systematic effort is highly laudable and is a long overdue development in ophthalmology. There is a remarkable and painful realization that over a period of more than 40 years, since the beginning of the worldwide popularization of so-called “prophylactic” treatment to prevent retinal detachment, there has been relatively little progress in understanding or change in attitudes about this subject. Although the PPP panel must be
15