- Email: [email protected]
The fellow eye of patients with rhegmatogenous retinal detachment
The Fellow Eye of Patients with Rhegmatogenous Retinal Detachment Christine R. Gonzales, MD, Anurag Gupta, MD, Steven D. Schwartz, MD, Allan E. Kreiger, MD Objective: To determine how often the fellow eyes of patients with rhegmatogenous retinal detachment (RRD) without proliferative vitreoretinopathy (PVR) harbor vision-threatening conditions at presentation and during follow-up. Design: Retrospective, observational case series. Participants: Two hundred forty-eight patients with RRD without PVR were studied. Intervention: The authors observed the fellow eye of patients with RRD for vision-threatening pathology. Main Outcome Measure: Detection of vision-threatening pathology in the fellow eye of patients with RRD without PVR. Results: Two hundred forty-eight patients were observed for an average of 5.2 years. One hundred fifty-seven vision-threatening events or diagnoses occurred in the fellow eye, including pre-existing and newly diagnosed conditions, 97 (62%) of which were rhegmatogenous in nature. Fifty-six patients (23%) had retinal detachments in their fellow eye, including those with a history of RRD repair (28 eyes), those presenting with bilateral RRD (4 eyes), and those developing new RRD during follow-up (24 eyes). In addition, 1 patient developed recurrent retinal detachment in the fellow eye during follow-up. Retinal tears were diagnosed and treated with laser retinopexy or cryotherapy in 30 (12%) fellow eyes (4 before the initial examination, 7 upon initial examination, and 19 on follow-up). Lattice degeneration was present in 27 (11%) fellow eyes. Conclusions: Patients who develop RRD are at considerable risk for developing vision-threatening events, particularly rhegmatogenous events, in the fellow eye. Ophthalmology 2004;111:518 –521 © 2004 by the American Academy of Ophthalmology.
Retinal detachment is a devastating ocular condition that often leaves a patient with limited vision in one eye. We know from prior studies that patients with rhegmatogenous retinal detachment (RRD) are at increased risk for developing retinal detachment in their fellow eyes. The incidence of bilateral RRD is not precisely known, but bilateral RRD has been reported in 7% to 33% of patients.1–5 This wide range of findings may be due, in part, to the inclusion of phakic, pseudophakic, and aphakic patients in these studies. Peripheral retinal lesions that may predispose patients to retinal detachment have been identified frequently in the fellow eyes. Retinal breaks have been demonstrated in 19% to 21%6 – 8 and lattice degeneration in 18% to 24% of fellow eyes.6 –9 Everett referred to “the fellow eye syndrome” to describe symmetrical degenerative retinal changes, which may be precursors to retinal detachment.10 Despite this attention to the fellow eye, the frequency of other visionthreatening conditions and the frequency with which patients with RRD lose vision in the fellow eye are rarely reported. Originally received: December 2, 2002. Accepted: June 18, 2003. Manuscript no. 220938. From the Jules Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California. Supported in part by a grant from Research to Prevent Blindness, New York, New York. Correspondence to Christine R. Gonzales, MD, Jules Stein Eye Institute, 100 Stein Plaza, Los Angeles, CA 90095. E-mail: [email protected].
518
© 2004 by the American Academy of Ophthalmology Published by Elsevier Inc.
Previous review of the fellow eye of patients with RRD and proliferative vitreoretinopathy (PVR) (grade C-3 or greater) from the practice of one of the authors (AEK) revealed that vision-threatening conditions occurred in 50% of fellow eyes.11 Seventy-four percent of these conditions were rhegmatogenous in nature. It is unknown whether the fellow eyes of patients with PVR-related retinal detachments behave differently from those without PVR. This issue prompted us to investigate the fellow eye of patients with RRD with less than grade C-3 PVR to determine how often the fellow eye harbors vision-threatening conditions.
Materials and Methods Institutional review board/ethics committee approval was obtained for this study. All patients diagnosed with RRD between March 1970 and April 1999 were identified from the clinical database of a single surgeon (AEK) at the Jules Stein Eye Institute. Patients with retinal detachment who did not have a posterior vitreous detachment (PVD) and patients with PVR greater than or equal to grade C-3 in the primary eye, as defined elsewhere,12 were excluded. These patients were studied separately11 (Gonzales, unpublished data). Information recorded in the medical chart enabled us to identify and exclude patients with retinal detachment in the absence of PVD. Additionally, patients with giant retinal tears, retinopathy of prematurity, traumatic retinal detachment, or diabetes-related retinal detachments were excluded. Patients with ⬍6 months of documented follow-up were excluded. For patients lacking appropriate follow-up with Dr Kreiger, the patient or the ISSN 0161-6420/04/$–see front matter doi:10.1016/j.ophtha.2003.06.011
Gonzales et al 䡠 The Fellow Eye of Patients with Rhegmatogenous Retinal Detachment Table 2. Type of Surgical Repair in Primary Eye Type of Surgery
N
Scleral buckle Revision of scleral buckle Scleral buckle with gas Scleral buckle with pars plana vitrectomy Pneumatic retinopexy Photocoagulation Scleral buckle with cataract extraction None Total
218 17 4 3 3 1 1 1 248
Figure 1. Distribution of follow-up.
patient’s ophthalmologist was contacted to retrieve further follow-up information. A thorough chart review was performed, and the relevant clinical data were recorded. A vision-threatening diagnosis or event was defined as any diagnosis that might negatively affect vision. Included was the diagnosis of visually significant cataract for which surgery was recommended and the patient refused surgery. Retinal lesions such as lattice degeneration and cystic retinal tufts were not counted as a vision-threatening diagnosis unless associated with a retinal hole or tear. Similarly, myopia was not counted as a vision-threatening diagnosis unless myopic degeneration was present.
Results Two hundred sixty-two patients with RRD associated with PVD and with less than grade C-3 PVR were identified. Of these, 248 (151 men and 97 women) had ⱖ6 months of documented followup; 14 patients were excluded for insufficient follow-up. The mean age of the patients was 61.0 years (median, 63.0; range, 9 – 87). The follow-up interval was between 6 and 301 months, with a mean of 63.4 months. Figure 1 shows the distribution of follow-up for the study patients. The characteristics of the retinal detachment in the primary eye upon presentation are listed in Table 1. All 248 patients, except 1 with no light perception vision secondary to chronic open-angle glaucoma, had retinal detachment surgical repair at the Jules Stein Eye Institute by one surgeon (AEK), as listed in Table 2. Recurrent retinal detachment occurred in 19 primary eyes after this initial surgery. All 19 retinal detachments were successfully repaired with scleral buckle revision, pars plana vitrectomy, or a combination of these procedures. The findings in the fellow eye on the initial examination are listed in Table 3. Prior retinal detachment surgery was noted in 28 patients, and 4 new retinal detachments were diagnosed in the fellow eye on the initial examination. All 4 of these retinal detachments were successfully repaired with the scleral buckling procedure (1 subclinical retinal detachment was observed initially but progressed on follow-up, requiring a scleral buckle procedure). Table 1. Classification of Retinal Detachment (RD) in the Primary Eye Type of RD
N (%)
Primary aphakic RD Primary phakic RD Primary pseudophakic RD Recurrent RD Total
67 (27) 107 (43) 45 (18) 29 (12) 248
Seven patients had tractional retinal tears without retinal detachment diagnosed on the initial examination that were treated with laser retinopexy or cryotherapy; 4 had findings consistent with past laser therapy retinopexy or cryotherapy for old retinal tears. Only 1 of the new retinal tears was associated with lattice degeneration. Lattice degeneration was noted in the fellow eye in 27 (11%) of the patients at presentation. Of these, 7 had atrophic holes within the area of lattice, 4 of which were treated with laser retinopexy or cryotherapy by one of the authors (AEK) after the initial examination. Nine patients were treated with cryotherapy or laser for lattice degeneration without retinal breaks after the initial examination. On initial examination, 58% of fellow eyes were phakic, and 11% had visually significant cataracts. Eleven percent of patients had ⱖ6 diopters of myopia, and 7% had glaucoma in the fellow eye. Other nonrhegmatogenous conditions in the fellow eye noted upon the initial examination are listed in Table 3. Vision-threatening events occurring in the fellow eye during follow-up are listed in Table 4. Sixty-seven new vision-threatening problems were detected in the fellow eye during follow-up; 44 (66%) of these were rhegmatogenous in nature. Rhegmatogenous retinal detachment was diagnosed in the fellow eye in 25 patients after the initial examination during followup. One of these was a recurrent retinal detachment that had previously been repaired with a scleral buckling procedure. Twenty of the 25 patients underwent the scleral buckling procedure, 1 had vitrectomy and silicone oil, 1 had cryotherapy, and 1 had a scleral buckle revision. One patient’s retinal detachment was repaired at an outside facility; the type of surgical repair is unknown. One patient was observed without progression of the retinal detachment. Of the 20 patients with scleral buckles, 4 had recurrent retinal detachments and underwent scleral buckle revisions. One of these 4 required a third retinal surgery with silicone oil for recurrent retinal detachment and PVR. This eye eventually became phthisical. Overall, 56 patients (23%) experienced retinal detachment in the fellow eye, including those who had been previously treated (28 eyes), those diagnosed on the initial examination (4 eyes), and those noted on follow-up (24 eyes). In addition, 1 patient experienced recurrent retinal detachment after scleral buckling surgery during follow-up in the fellow eye that was successfully repaired with scleral buckle revision. Retinal tears were diagnosed and treated with laser retinopexy or cryotherapy in 30 (12%) patients (4 before the initial examination, 7 upon initial examination, and 19 on follow-up). Two of the newly diagnosed tears were associated with lattice degeneration, and 2 were in patients who had prior scleral buckling surgery. Forty patients underwent cataract surgery at some point during the follow-up interval. Three patients with visual acuity worse than 20/50 in the fellow eye, thought to be secondary to cataract by the examining ophthalmologist, declined cataract surgery despite the
519
Ophthalmology Volume 111, Number 3, March 2004 Table 3. Findings in the Fellow Eye on Initial Examination Findings History of repair of RD History of scleral buckle History of RD repair (unknown type) History of pneumatic retinopexy History of pars plana vitrectomy New RD diagnosed Primary aphakic RD Subclinical RD Phakic RD New retinal holes/tears Atrophic retinal holes* Retinal tear History of laser retinopexy or cryotherapy Retinal tears Lattice degeneration without holes Lattice degeneration/hole Other peripheral retinal pathology Lattice degeneration Cystic retinal tuft Sequelae of RD† Maculopathy from prior RD Blind from unsuccessful RD repair Lens status‡ Visually significant cataract§ Pseudophakia Aphakia Phakia Unknown Refractive state㛳 High myopia Low myopia Other ocular conditions Chronic open-angle glaucoma Macular pucker Myopic degeneration Age-related macular degeneration Anophthalmis Pseudophakic bullous keratopathy Presumed ocular histoplasmosis syndrome Nonproliferative diabetic retinopathy Fuch’s corneal dystrophy Blind from vascular event Inactive chorioretinitis Congenital nystagmus Familial exudative vitreoretinopathy Iris tumor Phthisis
Table 4. Vision-Threatening Events/Diagnoses in the Fellow Eye during Follow-up N 28 23 3 1 1 4 2 1 1 15 8 7 10 4 4 2 28 27 1 10 2 8
26 37 36 142 4 32 17 37 17 3 3 2 2 1 1 1 1 1 1 1 1 1 1
RD ⫽ retinal detachment. *Seven of the 8 atrophic holes were associated with lattice degeneration. † These 10 patients were counted with those having a history of RD repair. ‡ Two patients with prostheses and 1 with phthisis are not included in this total. § Defined as nuclear sclerosis or posterior subcapsular cataract associated with visual acuity of ⱕ20/40 in which visual deficit was not due to other ocular pathology. 㛳 High myopia was defined as ⬎6 diopters (D); low myopia, ⱕ6 D.
surgeon’s recommendation. These 3 cataracts were counted as vision-threatening diagnoses. Overall, 157 vision-threatening events or diagnoses occurred in the fellow eye, including those pre-existing and newly diagnosed, 97 (62%) of which were rhegmatogenous in nature. Final visual acuity data for the fellow eye with vision-threatening pathology are presented in Table 5, and initial and final
520
Event/Diagnosis Rhegmatogenous events Retinal tear without detachment Retinal detachment Total rhegmatogenous events Nonrhegmatogenous events/diagnoses Age-related macular degeneration Chronic open-angle glaucoma Cataract Corneal edema Phthisis New PVD without retinal tear Neurologic visual loss Macular hole Diabetic retinopathy Herpes zoster keratitis Total nonrhegmatogenous diagnoses Total
N 19 25* 44 8 4† 3‡ 2 1 1 1 1 1 1 23 67
PVD ⫽ posterior vitreous detachment. *One of these detachments was recurrent. † Two of these patients required glaucoma surgery. ‡ These patients had visual acuity of ⱕ20/60 secondary to cataract and refused surgery.
visual acuities for all fellow eyes meeting entry criteria are presented in Table 6.
Discussion Schwartz and Kreiger demonstrated a definite risk to the fellow eye in patients with RRD associated with PVR (grade C-3 or more).11 In their retrospective study of 249 patients, 109 (53%) patients demonstrated vision-threatening pathology in the fellow eye. Of the 109 vision-threatening diagnoses, 81 (74%) were rhegmatogenous in nature. We studied the fellow eye of patients from the same surgeon’s practice who presented with retinal detachment and less than grade C-3 PVR. One hundred twenty-nine patients (52%) in our study demonstrated vision-threatening pathology in the fellow eye; 97 of 157 (62%) of the visionthreatening diagnoses were rhegmatogenous in nature. Comparing our findings with those reported by Schwartz and Kreiger, the risk of vision-threatening events in the fellow eye seems to be similar in patients with and without PVR. The proportion of vision-threatening diagnoses that were rhegmatogenous in nature, however, was slightly less Table 5. Final Visual Acuity of Fellow Eyes with VisionThreatening Pathology Visual Acuity
N (%)
ⱖ20/40 20/50 to 20/200 20/300 to LP NLP
78 (63) 27 (22) 9 (7) 10 (8)
LP ⫽ light perception; NLP ⫽ no LP.
Gonzales et al 䡠 The Fellow Eye of Patients with Rhegmatogenous Retinal Detachment Table 6. Visual Acuity of Fellow Eyes Visual Acuity
Initial (%)
Final (%)
ⱖ20/40 20/50 to 20/200 20/300 to LP NLP
196 (80) 35 (14) 6 (2) 9 (4)
183 (79) 31 (13) 8 (3) 10 (4)
LP ⫽ light perception; NLP ⫽ no LP.
for the fellow eye of patients without PVR than for eyes with retinal detachment and PVR in the primary eye. Most patients (79%) maintained a visual acuity of 20/40 or better in the fellow eye, which is similar to that reported elsewhere.4,11 For those with vision-threatening diagnoses, 37% had a final visual acuity of 20/50 or worse in the fellow eye, which is only slightly better than previously reported (47%) in the fellow eye of patients with PVR in the primary eye.11 Pathologic vitreoretinal changes predisposing to retinal detachment were found frequently in the fellow eyes. Lattice degeneration was present in 23% of fellow eyes, retinal tears in 12%, and retinal holes in 4%. These findings are similar to those published in prior reports.6 –9 One might argue whether an atrophic retinal hole should be considered a predisposing lesion or vision-threatening diagnosis. Merin and colleagues studied fellow eyes of patients with RRD in the primary eye and found that 20% of fellow eyes with retinal holes progressed to retinal detachment, but they included “horseshoe-shaped holes” in this count, which are clearly different than atrophic retinal holes.6 Davis reported that 2 of 6 fellow eyes (33%) with atrophic holes plus subclinical retinal detachment progressed to clinical RRD, and that 2 of 45 (4.4%) without subclinical retinal detachment on initial examination developed clinical RRD on follow-up.13 Byer, on the other hand, reported a much lower risk of atrophic holes progressing to clinical retinal detachment.14 None of the 153 eyes with atrophic holes without subclinical retinal detachment progressed to clinical retinal detachment; however, these were nonfellow eyes, which may have a natural history different from that of fellow eyes of patients with RRD in the other eye. Retinal detachment occurred in the fellow eye in 23% of patients. The reported incidence of retinal detachment in the literature varies, ranging between 7% and 33%, which is due, in part, to the inclusion of phakic, psuedophakic, and aphakic retinal detachment in these studies.1–5 Benson et al studied each of these groups separately and demonstrated a 7% incidence of retinal detachment in the phakic fellow eye, whereas 26% of aphakic fellow eyes developed retinal detachment.4 The mean follow-up interval in our study of 5.2 years, although much longer than that of most series, still probably underestimates the number of eyes that would eventually develop retinal detachment. Delaney and Oates
reported an interval between retinal detachment in the first and second eye of up to 30 years, with a mean of 5.2 years.2 This study is limited by its retrospective nature. It is a review from a single surgeon’s practice from a tertiary referral center, which may bias the results. On the other hand, all patients had ⱖ6 months of follow-up with detailed retinal drawings, which allowed retrospective analysis of the findings. The study design is identical to that used in the prior fellow eye study of patients with greater than grade C-3 PVR, which facilitates comparison of findings. In summary, vision-threatening diagnoses occur frequently in the fellow eye of patients with RRD without PVR. These diagnoses are often rhegmatogenous in nature. Although many of these diagnoses are present on initial examination, they often occur during follow-up. Thus, the fellow eye should be carefully examined initially and followed closely over the long term.
References 1. Schepens CL, Marden D. Data on the natural history of retinal detachment: further characterization of certain unilateral nontraumatic cases. Am J Ophthalmol 1966;61:213– 6. 2. Delaney WV Jr, Oates RP. Retinal detachment in the second eye. Arch Ophthalmol 1978;96:629 –34. 3. Folk JC, Burton TC. Bilateral phakic retinal detachment. Ophthalmology 1982;89:815–20. 4. Benson WE, Grand MG, Okun E. Aphakic retinal detachment: management of the fellow eye. Arch Ophthalmol 1975;93: 245–9. 5. To¨ rnquist R. Bilateral retinal detachment. Acta Ophthalmol (Copenh) 1963;41:126 –33. 6. Merin S, Feiler V, Hyams S, et al. The fate of the fellow eye in retinal detachment. Am J Ophthalmol 1971;71:477– 81. 7. Lorentzen SE. Frequency of lattice degeneration and retinal breaks in the fellow eye in retinal detachment. Acta Ophthalmol (Copenh) 1988;66:157– 60. 8. Ciurlo G, Zingirian M, Rossi P. The fellow eye in retinal detachment. Albrecht Von Graefes Arch Klin Exp Ophthalmol 1980;214:83–7. 9. Laatikainen L. The fellow eye in patients with unilateral retinal detachment: findings and prophylactic treatment. Acta Ophthalmol (Copenh) 1985;63:546 –51. 10. Everett WG. The fellow eye syndrome in retinal detachment. Am J Ophthalmol 1963;56:739 – 48. 11. Schwartz SD, Kreiger AE. Proliferative vitreoretinopathy: a natural history of the fellow eye. Ophthalmology 1998;105: 785– 8. 12. Retina Society Terminology Committee. The classification of retinal detachment with proliferative vitreoretinopathy. Ophthalmology 1983;90:121–5. 13. Davis MD. The natural history of retinal breaks without detachment. Trans Am Ophthalmol Soc 1973;71:343–72. 14. Byer NE. What happens to untreated asymptomatic retinal breaks, and are they affected by posterior vitreous detachment? Ophthalmology 1998;105:1045–50.
521
Retinal detachment is a devastating ocular condition that often leaves a patient with limited vision in one eye. We know from prior studies that patients with rhegmatogenous retinal detachment (RRD) are at increased risk for developing retinal detachment in their fellow eyes. The incidence of bilateral RRD is not precisely known, but bilateral RRD has been reported in 7% to 33% of patients.1–5 This wide range of findings may be due, in part, to the inclusion of phakic, pseudophakic, and aphakic patients in these studies. Peripheral retinal lesions that may predispose patients to retinal detachment have been identified frequently in the fellow eyes. Retinal breaks have been demonstrated in 19% to 21%6 – 8 and lattice degeneration in 18% to 24% of fellow eyes.6 –9 Everett referred to “the fellow eye syndrome” to describe symmetrical degenerative retinal changes, which may be precursors to retinal detachment.10 Despite this attention to the fellow eye, the frequency of other visionthreatening conditions and the frequency with which patients with RRD lose vision in the fellow eye are rarely reported. Originally received: December 2, 2002. Accepted: June 18, 2003. Manuscript no. 220938. From the Jules Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California. Supported in part by a grant from Research to Prevent Blindness, New York, New York. Correspondence to Christine R. Gonzales, MD, Jules Stein Eye Institute, 100 Stein Plaza, Los Angeles, CA 90095. E-mail: [email protected].
518
© 2004 by the American Academy of Ophthalmology Published by Elsevier Inc.
Previous review of the fellow eye of patients with RRD and proliferative vitreoretinopathy (PVR) (grade C-3 or greater) from the practice of one of the authors (AEK) revealed that vision-threatening conditions occurred in 50% of fellow eyes.11 Seventy-four percent of these conditions were rhegmatogenous in nature. It is unknown whether the fellow eyes of patients with PVR-related retinal detachments behave differently from those without PVR. This issue prompted us to investigate the fellow eye of patients with RRD with less than grade C-3 PVR to determine how often the fellow eye harbors vision-threatening conditions.
Materials and Methods Institutional review board/ethics committee approval was obtained for this study. All patients diagnosed with RRD between March 1970 and April 1999 were identified from the clinical database of a single surgeon (AEK) at the Jules Stein Eye Institute. Patients with retinal detachment who did not have a posterior vitreous detachment (PVD) and patients with PVR greater than or equal to grade C-3 in the primary eye, as defined elsewhere,12 were excluded. These patients were studied separately11 (Gonzales, unpublished data). Information recorded in the medical chart enabled us to identify and exclude patients with retinal detachment in the absence of PVD. Additionally, patients with giant retinal tears, retinopathy of prematurity, traumatic retinal detachment, or diabetes-related retinal detachments were excluded. Patients with ⬍6 months of documented follow-up were excluded. For patients lacking appropriate follow-up with Dr Kreiger, the patient or the ISSN 0161-6420/04/$–see front matter doi:10.1016/j.ophtha.2003.06.011
Gonzales et al 䡠 The Fellow Eye of Patients with Rhegmatogenous Retinal Detachment Table 2. Type of Surgical Repair in Primary Eye Type of Surgery
N
Scleral buckle Revision of scleral buckle Scleral buckle with gas Scleral buckle with pars plana vitrectomy Pneumatic retinopexy Photocoagulation Scleral buckle with cataract extraction None Total
218 17 4 3 3 1 1 1 248
Figure 1. Distribution of follow-up.
patient’s ophthalmologist was contacted to retrieve further follow-up information. A thorough chart review was performed, and the relevant clinical data were recorded. A vision-threatening diagnosis or event was defined as any diagnosis that might negatively affect vision. Included was the diagnosis of visually significant cataract for which surgery was recommended and the patient refused surgery. Retinal lesions such as lattice degeneration and cystic retinal tufts were not counted as a vision-threatening diagnosis unless associated with a retinal hole or tear. Similarly, myopia was not counted as a vision-threatening diagnosis unless myopic degeneration was present.
Results Two hundred sixty-two patients with RRD associated with PVD and with less than grade C-3 PVR were identified. Of these, 248 (151 men and 97 women) had ⱖ6 months of documented followup; 14 patients were excluded for insufficient follow-up. The mean age of the patients was 61.0 years (median, 63.0; range, 9 – 87). The follow-up interval was between 6 and 301 months, with a mean of 63.4 months. Figure 1 shows the distribution of follow-up for the study patients. The characteristics of the retinal detachment in the primary eye upon presentation are listed in Table 1. All 248 patients, except 1 with no light perception vision secondary to chronic open-angle glaucoma, had retinal detachment surgical repair at the Jules Stein Eye Institute by one surgeon (AEK), as listed in Table 2. Recurrent retinal detachment occurred in 19 primary eyes after this initial surgery. All 19 retinal detachments were successfully repaired with scleral buckle revision, pars plana vitrectomy, or a combination of these procedures. The findings in the fellow eye on the initial examination are listed in Table 3. Prior retinal detachment surgery was noted in 28 patients, and 4 new retinal detachments were diagnosed in the fellow eye on the initial examination. All 4 of these retinal detachments were successfully repaired with the scleral buckling procedure (1 subclinical retinal detachment was observed initially but progressed on follow-up, requiring a scleral buckle procedure). Table 1. Classification of Retinal Detachment (RD) in the Primary Eye Type of RD
N (%)
Primary aphakic RD Primary phakic RD Primary pseudophakic RD Recurrent RD Total
67 (27) 107 (43) 45 (18) 29 (12) 248
Seven patients had tractional retinal tears without retinal detachment diagnosed on the initial examination that were treated with laser retinopexy or cryotherapy; 4 had findings consistent with past laser therapy retinopexy or cryotherapy for old retinal tears. Only 1 of the new retinal tears was associated with lattice degeneration. Lattice degeneration was noted in the fellow eye in 27 (11%) of the patients at presentation. Of these, 7 had atrophic holes within the area of lattice, 4 of which were treated with laser retinopexy or cryotherapy by one of the authors (AEK) after the initial examination. Nine patients were treated with cryotherapy or laser for lattice degeneration without retinal breaks after the initial examination. On initial examination, 58% of fellow eyes were phakic, and 11% had visually significant cataracts. Eleven percent of patients had ⱖ6 diopters of myopia, and 7% had glaucoma in the fellow eye. Other nonrhegmatogenous conditions in the fellow eye noted upon the initial examination are listed in Table 3. Vision-threatening events occurring in the fellow eye during follow-up are listed in Table 4. Sixty-seven new vision-threatening problems were detected in the fellow eye during follow-up; 44 (66%) of these were rhegmatogenous in nature. Rhegmatogenous retinal detachment was diagnosed in the fellow eye in 25 patients after the initial examination during followup. One of these was a recurrent retinal detachment that had previously been repaired with a scleral buckling procedure. Twenty of the 25 patients underwent the scleral buckling procedure, 1 had vitrectomy and silicone oil, 1 had cryotherapy, and 1 had a scleral buckle revision. One patient’s retinal detachment was repaired at an outside facility; the type of surgical repair is unknown. One patient was observed without progression of the retinal detachment. Of the 20 patients with scleral buckles, 4 had recurrent retinal detachments and underwent scleral buckle revisions. One of these 4 required a third retinal surgery with silicone oil for recurrent retinal detachment and PVR. This eye eventually became phthisical. Overall, 56 patients (23%) experienced retinal detachment in the fellow eye, including those who had been previously treated (28 eyes), those diagnosed on the initial examination (4 eyes), and those noted on follow-up (24 eyes). In addition, 1 patient experienced recurrent retinal detachment after scleral buckling surgery during follow-up in the fellow eye that was successfully repaired with scleral buckle revision. Retinal tears were diagnosed and treated with laser retinopexy or cryotherapy in 30 (12%) patients (4 before the initial examination, 7 upon initial examination, and 19 on follow-up). Two of the newly diagnosed tears were associated with lattice degeneration, and 2 were in patients who had prior scleral buckling surgery. Forty patients underwent cataract surgery at some point during the follow-up interval. Three patients with visual acuity worse than 20/50 in the fellow eye, thought to be secondary to cataract by the examining ophthalmologist, declined cataract surgery despite the
519
Ophthalmology Volume 111, Number 3, March 2004 Table 3. Findings in the Fellow Eye on Initial Examination Findings History of repair of RD History of scleral buckle History of RD repair (unknown type) History of pneumatic retinopexy History of pars plana vitrectomy New RD diagnosed Primary aphakic RD Subclinical RD Phakic RD New retinal holes/tears Atrophic retinal holes* Retinal tear History of laser retinopexy or cryotherapy Retinal tears Lattice degeneration without holes Lattice degeneration/hole Other peripheral retinal pathology Lattice degeneration Cystic retinal tuft Sequelae of RD† Maculopathy from prior RD Blind from unsuccessful RD repair Lens status‡ Visually significant cataract§ Pseudophakia Aphakia Phakia Unknown Refractive state㛳 High myopia Low myopia Other ocular conditions Chronic open-angle glaucoma Macular pucker Myopic degeneration Age-related macular degeneration Anophthalmis Pseudophakic bullous keratopathy Presumed ocular histoplasmosis syndrome Nonproliferative diabetic retinopathy Fuch’s corneal dystrophy Blind from vascular event Inactive chorioretinitis Congenital nystagmus Familial exudative vitreoretinopathy Iris tumor Phthisis
Table 4. Vision-Threatening Events/Diagnoses in the Fellow Eye during Follow-up N 28 23 3 1 1 4 2 1 1 15 8 7 10 4 4 2 28 27 1 10 2 8
26 37 36 142 4 32 17 37 17 3 3 2 2 1 1 1 1 1 1 1 1 1 1
RD ⫽ retinal detachment. *Seven of the 8 atrophic holes were associated with lattice degeneration. † These 10 patients were counted with those having a history of RD repair. ‡ Two patients with prostheses and 1 with phthisis are not included in this total. § Defined as nuclear sclerosis or posterior subcapsular cataract associated with visual acuity of ⱕ20/40 in which visual deficit was not due to other ocular pathology. 㛳 High myopia was defined as ⬎6 diopters (D); low myopia, ⱕ6 D.
surgeon’s recommendation. These 3 cataracts were counted as vision-threatening diagnoses. Overall, 157 vision-threatening events or diagnoses occurred in the fellow eye, including those pre-existing and newly diagnosed, 97 (62%) of which were rhegmatogenous in nature. Final visual acuity data for the fellow eye with vision-threatening pathology are presented in Table 5, and initial and final
520
Event/Diagnosis Rhegmatogenous events Retinal tear without detachment Retinal detachment Total rhegmatogenous events Nonrhegmatogenous events/diagnoses Age-related macular degeneration Chronic open-angle glaucoma Cataract Corneal edema Phthisis New PVD without retinal tear Neurologic visual loss Macular hole Diabetic retinopathy Herpes zoster keratitis Total nonrhegmatogenous diagnoses Total
N 19 25* 44 8 4† 3‡ 2 1 1 1 1 1 1 23 67
PVD ⫽ posterior vitreous detachment. *One of these detachments was recurrent. † Two of these patients required glaucoma surgery. ‡ These patients had visual acuity of ⱕ20/60 secondary to cataract and refused surgery.
visual acuities for all fellow eyes meeting entry criteria are presented in Table 6.
Discussion Schwartz and Kreiger demonstrated a definite risk to the fellow eye in patients with RRD associated with PVR (grade C-3 or more).11 In their retrospective study of 249 patients, 109 (53%) patients demonstrated vision-threatening pathology in the fellow eye. Of the 109 vision-threatening diagnoses, 81 (74%) were rhegmatogenous in nature. We studied the fellow eye of patients from the same surgeon’s practice who presented with retinal detachment and less than grade C-3 PVR. One hundred twenty-nine patients (52%) in our study demonstrated vision-threatening pathology in the fellow eye; 97 of 157 (62%) of the visionthreatening diagnoses were rhegmatogenous in nature. Comparing our findings with those reported by Schwartz and Kreiger, the risk of vision-threatening events in the fellow eye seems to be similar in patients with and without PVR. The proportion of vision-threatening diagnoses that were rhegmatogenous in nature, however, was slightly less Table 5. Final Visual Acuity of Fellow Eyes with VisionThreatening Pathology Visual Acuity
N (%)
ⱖ20/40 20/50 to 20/200 20/300 to LP NLP
78 (63) 27 (22) 9 (7) 10 (8)
LP ⫽ light perception; NLP ⫽ no LP.
Gonzales et al 䡠 The Fellow Eye of Patients with Rhegmatogenous Retinal Detachment Table 6. Visual Acuity of Fellow Eyes Visual Acuity
Initial (%)
Final (%)
ⱖ20/40 20/50 to 20/200 20/300 to LP NLP
196 (80) 35 (14) 6 (2) 9 (4)
183 (79) 31 (13) 8 (3) 10 (4)
LP ⫽ light perception; NLP ⫽ no LP.
for the fellow eye of patients without PVR than for eyes with retinal detachment and PVR in the primary eye. Most patients (79%) maintained a visual acuity of 20/40 or better in the fellow eye, which is similar to that reported elsewhere.4,11 For those with vision-threatening diagnoses, 37% had a final visual acuity of 20/50 or worse in the fellow eye, which is only slightly better than previously reported (47%) in the fellow eye of patients with PVR in the primary eye.11 Pathologic vitreoretinal changes predisposing to retinal detachment were found frequently in the fellow eyes. Lattice degeneration was present in 23% of fellow eyes, retinal tears in 12%, and retinal holes in 4%. These findings are similar to those published in prior reports.6 –9 One might argue whether an atrophic retinal hole should be considered a predisposing lesion or vision-threatening diagnosis. Merin and colleagues studied fellow eyes of patients with RRD in the primary eye and found that 20% of fellow eyes with retinal holes progressed to retinal detachment, but they included “horseshoe-shaped holes” in this count, which are clearly different than atrophic retinal holes.6 Davis reported that 2 of 6 fellow eyes (33%) with atrophic holes plus subclinical retinal detachment progressed to clinical RRD, and that 2 of 45 (4.4%) without subclinical retinal detachment on initial examination developed clinical RRD on follow-up.13 Byer, on the other hand, reported a much lower risk of atrophic holes progressing to clinical retinal detachment.14 None of the 153 eyes with atrophic holes without subclinical retinal detachment progressed to clinical retinal detachment; however, these were nonfellow eyes, which may have a natural history different from that of fellow eyes of patients with RRD in the other eye. Retinal detachment occurred in the fellow eye in 23% of patients. The reported incidence of retinal detachment in the literature varies, ranging between 7% and 33%, which is due, in part, to the inclusion of phakic, psuedophakic, and aphakic retinal detachment in these studies.1–5 Benson et al studied each of these groups separately and demonstrated a 7% incidence of retinal detachment in the phakic fellow eye, whereas 26% of aphakic fellow eyes developed retinal detachment.4 The mean follow-up interval in our study of 5.2 years, although much longer than that of most series, still probably underestimates the number of eyes that would eventually develop retinal detachment. Delaney and Oates
reported an interval between retinal detachment in the first and second eye of up to 30 years, with a mean of 5.2 years.2 This study is limited by its retrospective nature. It is a review from a single surgeon’s practice from a tertiary referral center, which may bias the results. On the other hand, all patients had ⱖ6 months of follow-up with detailed retinal drawings, which allowed retrospective analysis of the findings. The study design is identical to that used in the prior fellow eye study of patients with greater than grade C-3 PVR, which facilitates comparison of findings. In summary, vision-threatening diagnoses occur frequently in the fellow eye of patients with RRD without PVR. These diagnoses are often rhegmatogenous in nature. Although many of these diagnoses are present on initial examination, they often occur during follow-up. Thus, the fellow eye should be carefully examined initially and followed closely over the long term.
References 1. Schepens CL, Marden D. Data on the natural history of retinal detachment: further characterization of certain unilateral nontraumatic cases. Am J Ophthalmol 1966;61:213– 6. 2. Delaney WV Jr, Oates RP. Retinal detachment in the second eye. Arch Ophthalmol 1978;96:629 –34. 3. Folk JC, Burton TC. Bilateral phakic retinal detachment. Ophthalmology 1982;89:815–20. 4. Benson WE, Grand MG, Okun E. Aphakic retinal detachment: management of the fellow eye. Arch Ophthalmol 1975;93: 245–9. 5. To¨ rnquist R. Bilateral retinal detachment. Acta Ophthalmol (Copenh) 1963;41:126 –33. 6. Merin S, Feiler V, Hyams S, et al. The fate of the fellow eye in retinal detachment. Am J Ophthalmol 1971;71:477– 81. 7. Lorentzen SE. Frequency of lattice degeneration and retinal breaks in the fellow eye in retinal detachment. Acta Ophthalmol (Copenh) 1988;66:157– 60. 8. Ciurlo G, Zingirian M, Rossi P. The fellow eye in retinal detachment. Albrecht Von Graefes Arch Klin Exp Ophthalmol 1980;214:83–7. 9. Laatikainen L. The fellow eye in patients with unilateral retinal detachment: findings and prophylactic treatment. Acta Ophthalmol (Copenh) 1985;63:546 –51. 10. Everett WG. The fellow eye syndrome in retinal detachment. Am J Ophthalmol 1963;56:739 – 48. 11. Schwartz SD, Kreiger AE. Proliferative vitreoretinopathy: a natural history of the fellow eye. Ophthalmology 1998;105: 785– 8. 12. Retina Society Terminology Committee. The classification of retinal detachment with proliferative vitreoretinopathy. Ophthalmology 1983;90:121–5. 13. Davis MD. The natural history of retinal breaks without detachment. Trans Am Ophthalmol Soc 1973;71:343–72. 14. Byer NE. What happens to untreated asymptomatic retinal breaks, and are they affected by posterior vitreous detachment? Ophthalmology 1998;105:1045–50.
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