EyeWorld India March 2012 Issue

48 EW RETINA March 2012 Evaluating the risks of retinal detachment in cataract patients by Michelle Dalton EyeWorld Contributing Editor Family history and refractive error are but two risk factors that increase the risk of a retinal detachment. Here, retinal experts discuss when—or if—to treat tears and holes R etinal detachments (RDs) are more likely to occur in patients with higher myopia, and the risk increases if there’s a family history of RD or if a patient’s fellow eye has had one. In these patients, retinal specialists recommend extra vigilance when looking at the peripheral retina during normal pre-op exams before cataract surgery. Refractive lens exchange patients undergoing an IOL exchange are also at a higher risk. Complicated cataract surgery—cases involving vitreous loss or capsular rupture—also puts the patient at an increased risk of developing an RD. Another patient group at risk is people who have undergone refractive surgery and no longer consider themselves myopic. Anatomically, those eyes are still longer and at risk, retina specialists said. Sometimes, regardless of how meticulous the surgeon is, an RD may still occur. Educating the patient about the signs and symptoms of RD can go a long way toward catching a tear before it becomes a full-blown detachment, experts said. “If patients are aware of the signs and symptoms of RD, they’ll be less likely to ignore floaters,” said David S. Boyer, MD, clinical professor of ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, Calif., USA. “Wound integrity is crucial as well. If someone has a clear corneal cataract surgery and you see vitreous in the wound, that’s a risk factor for retinal tears,” said Andrew A. Moshfeghi, MD, assistant professor of ophthalmology and medical director, Bascom Palmer Eye Institute, Palm Beach Gardens, Fla., USA. Likewise, if patients do have increased risk factors, silicone IOLs and multifocal IOLs can make treatment of a detachment more difficult because visualization is hampered, said Amani Fawzi, MD, associate professor of ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Ill., USA. Lastly, a younger patient age can also increase the risk, said Jay M. Stewart, MD, associate professor of ophthalmology, School of Medicine, University of California, San Francisco, Calif., USA. “A study by Ripandelli and co- workers published in Ophthalmology in 2007 found that younger patients had a higher likelihood of developing a retinal detachment following cataract surgery, and most postoperative posterior vitreous detachments occurred in young patients.” 1 Patients who seek treatment “too late in the course of the disease because they’re unfamiliar with the symptoms” are most likely to have poor visual outcomes as well, Dr. Stewart said. “Once central vision has been impacted by an RD, the outcomes are not as good.” Dr. Fawzi agreed, noting anterior segment surgeons should educate patients to pay attention to any floaters, flashing light, or curtain/veil coming across their visual fields in the first few weeks after cataract surgery. What to treat and when Any suspicious lesion in the retinal periphery bears examination and investigation, Dr. Stewart said. Retinal tears should be treated before the patient undergoes cataract surgery, and Dr. Boyer recommended allowing the tear to heal for “several weeks” before any other surgery. “Tears put patients at a marked increased risk of developing a detachment,” he said. “It takes about 17-18 days to get an 80% bond if you’re using lasers to treat.” Most horseshoe retinal tears need to be treated immediately, Dr. Moshfeghi said, unless there’s adequate pre-existing retinal scarring. Drs. Fawzi and Stewart are slightly more cautious, noting they’ll follow rather than treat asymptomatic patients. “In most cases, the incidental finding of a hole in an asymptomatic patient with no strong family history or no underlying medical conditions [for example, Marfan’s] probably doesn’t need treatment,” Dr. Stewart said. Everyone agreed, however, that tears are more worrisome than full- on holes, regardless of geography. “People can go their entire life with an atrophic round hole and never need treatment,” Dr. Moshfeghi said. What about lattice? Lattice—one of the most common peripheral retina changes—may or may not cause an RD, and hence its treatment is controversial. “Lattice is commonly found in eyes that harbor RD, but may not be a causative agent. And 10-15% of the normal population has lattice,” Dr. Moshfeghi said. Lattice puts a patient at a “slightly greater risk” for RD, Dr. Boyer said. Lattice is autosomal dominant, with a variable degree of expressivity. “About one-third of all RDs will have a patch of lattice in it, and many times—about 18-20% of the time—lattice will have holes in it,” he said. For Dr. Stewart, the decision point on treatment is multifactorial—if the patient has lattice degeneration and has had AT A GLANCE • High myopia, age, and family/ fellow eye history are all risk factors for developing retinal detachments • Patient education is crucial to avoid poor visual outcomes— the earlier patients notice the symptoms, the more likely they’ll have a good outcome after treatment • Primary vitrectomy is becoming more common in treating RD, even in phakic patients An example of a macula-off retinal detachment Source: David S. Boyer, MD continued on page 51