Asymptomatic Rhegmatogenous

Asymptomatic Rhegmatogenous Retinal Detachments

Roy

D.

Brod, MD; Harry

W.

Flynn, Jr, MD;

David A.

Lightman,

Objective: To describe the clinical characteristics and risk of progression of asymptomatic rhegmatogenous retinal detachments.

MD

tomatic without progression of the retinal detachment. Two eyes progressed to a symptomatic retinal detachment 2.25 and 3.3 years after the initial examination, un-

derwent a successful scleral buckling maintained 20/20 visual acuity.

procedure,

and

Methods: We retrospectively reviewed the clinical records of 28 patients (31 eyes) with asymptomatic rhegmatogenous retinal detachments followed up without surgery for 0.5 to 12.1 years (mean, 3.4 years). Tractional tears were present in six eyes and atrophic holes in 25 eyes. In five patients, the asymptomatic retinal detachment was noted when the patient presented with a symptomatic retinal detachment in the fellow eye.

Conclusions: Observation can be considered a reasonable option in the treatment of patients with asymptomatic retinal detachments. Chart documentation of the risks and benefits of observation and instruction of the patient on self-monitoring of the peripheral visual field are necessary in such patients.

Results:

(Arch Ophthalmol. 1995;113:1030-1032)

Twenty-nine of the 31

eyes remained asymp-

MOST

PATIENTS

with

rhegmatogenous reti¬

Department of Ophthalmology, Hershey (Pa) From the

Medical Center (Dr Brod); Bascom Palmer Eye Institute, Miami, Fla (Dr Flynn); and

Williamsport (Pa) Hospital

and Medical Center

(Dr Lightman).

nal detachments pre¬ sent with symptoms, which commonly include photopsias, floaters, and loss of peripheral or central vision. In these patients, repair of the retinal detachment is usually recommended to restore lost vi¬ sion or prevent further visual loss. Infre¬ quently, a rhegmatogenous retinal detach¬ ment is observed in an eye on a routine eye examination in an asymptomatic pa¬ tient. In these cases a demarcation line may be present, and there are often clinical signs that suggest chronicity, such as intrareti¬ nal macrocysts, thinning of the detached retina, and underlying retinal pigment epi¬ thelial alteration. The natural course of these asymptom¬ atic retinal detachments is unknown, and consequently management guidelines have not been published. It has been our impres¬ sion that most of these cases are nonprogres¬ sive, and observation may be an appropri¬ ate management option. The purpose of this study is to describe the clinical charac¬ teristics and incidence of progression of asymptomatic rhegmatogenous retinal de¬ tachments.

RESULTS

Eighteen of the 28 patients were female. The asymptomatic retinal detachment was pres¬ ent in the right eye only in nine patients, the left eye only in 16 patients, and both eyes in three patients. Their ages ranged from 17

82 years, with a mean age of 49 years. The spherical equivalent of the refrac¬ tion was available in 21 of the 27 phakic eyes. Fourteen (67%) of 21 had 5 diopters (D) or more of myopia. Two (9%) of 21 had between 2 and 5 D of myopia, and five (24%) of 21 had less than 2 D of myopia. Twenty-seven eyes (87.1%) were pha¬ kic, three (9.7%) were pseudophakic, and one (3.2%) was aphakic. Two of the three pseudophakic eyes had posterior chamber implants with intact posterior capsules. The other pseudophakic eye had an anterior chamber implant. In 16 (52%) of the 31 eyes, the posterior cortical vitreous was at¬ tached, and in 11 eyes (35%), a posterior cortical vitreous detachment was detected to

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PATIENTS AND METHODS We reviewed the clinical records of known

patients

with asymptomatic rhegmatogenous retinai detachments who presented between 1980 and 1993. A total of31 eyes in 28 patients were collected from the medical records departments of the Geisinger Medical Center (Danville, Pa), Bascom Palmer Eye Institute (Miami, Fla), and the private practices of two of us (R.D.B. and D.A.L.). All eyes included in the study had a definite retinal break that accounted for the retinal detachment. Eyes in which retinoschisis could not be ruled out were excluded. In addition, only eyes with at least 6 months of follow-up data available in which no treatment was recommended or performed were included in the study. The following data were obtained for each patient: age, sex, refraction, type and location of the retinal break, presence of lattice degeneration, de¬ tachment configuration, presence and extent of de¬ marcation lines, lens status, presence or absence of posterior vitreous detachment, and retinal status of the fellow eye. When recent follow-up data were not available, the patients were reexamined to obtain the most recent follow-up information.

clinical examination. In four eyes (13%), the status of the posterior cortical vitreous was not recorded on the pa¬ tient chart. The extent of retinal detachment included one quad¬ rant in 16 (52%) eyes and two quadrants in 14 (45%) eyes. One (3%) of the eyes had retinal detachments involving three quadrants. In nine eyes (29%), the retinal detach¬ ment involved at least one of the superior quadrants. Sub¬ retinal fluid extended at least 3 disc diameters from the reti¬ nal break. The retinal detachment extended posterior to the equator in 29 (94%) eyes but remained anterior to the equator in two (6%) eyes. In four eyes (13%), it extended to the vascular arcade, and in an additional four eyes (13%), it extended posterior to the arcade of vessels. A demarcation line was noted in 23 eyes (74%). The demarcation line bordered the entire posterior extent of the detachment in 14 eyes (45%), and only a portion of the detachment was bordered by a demarcation line in seven eyes (23%). A previous demarcation line beneath detached retina was documented in two eyes (6%). At least one retinal break was identified in detached retina in all study eyes. The causes of the retinal detachment were atrophie holes in 25 eyes (81%) and tractional tears in six eyes (19%). The retinal breaks that accounted for the detach¬ ment were located in the superior quadrants in eight eyes (26%) and in the inferior quadrants in 23 eyes (74%). Lat¬ tice degeneration was detected in 16 eyes (52%). Peripheral retinal abnormalities were detected in 12 fellow eyes (43%). These peripheral retinal findings included previous scierai buckling procedures for symptomatic reti¬ nal detachments in five eyes (18%), asymptomatic retinal detachments in three eyes (11%), lattice degeneration with¬ out holes in two eyes (7%), lattice degeneration with holes in one eye (4%), and retinoschisis in one eye (4%). on

The duration of follow-up ranged from 0.5 to 12.1 years, with a mean of 3.4 years. At the most recent followup, no detectable change in the extent of retinal detach¬ ment was observed in 29 (93.5%) of the 31 eyes. Two patients had progression to symptomatic reti¬ nal detachments. One of the patients, a 37-year-old woman, noted a shadow in the superior visual field and was found to

have progression of a previously present inferior asymp¬

tomatic detachment beyond the borders of a demarcation line. The posterior vitreous was attached. The retinal de¬

tachment extended to the edge of the fovea, and the visual acuity decreased from 20/20 to 20/30. The detachment oc¬ curred 3.3 years after the patient initially presented with the asymptomatic detachment. This patient underwent a

scierai buckling procedure, resulting in retinal reattach¬ ment with visual acuity returning to 20/20. The second patient with progression was a 42-yearold man. He presented with acute onset of a shadow in the inferior visual field 2.25 years after the asymptomatic reti¬ nal detachment was diagnosed. The vitreous, which had previously been attached, was now detached. A new su¬ perior rhegmatogenous retinal detachment caused by mul¬ tiple large tractional tears was present. The macula was at¬ tached, and the new detachment did not communicate with the old asymptomatic detachment. A scierai buckling pro¬ cedure was performed. At last follow-up, the visual acuity was 20/20, with complete reattachment of the retina. Both of these patients were phakic and both had retinal detach¬ ments in the fellow eye. In one of these patients the retinal detachment in the fellow eye was asymptomatic, and in the other a scierai buckling procedure had been performed for a symptomatic detachment several years previously. COMMENT

Several options are available for the management of symp¬ tomatic rhegmatogenous retinal detachments; these in¬ clude a scierai buckling procedure, vitrectomy with gas tamponade, pneumatic retinopexy, and Lincoff bal¬ loon.1 The surgical procedure chosen varies with the clini¬ cal findings and surgeon preference; however, repair is almost always recommended in an eye with a symptom¬ atic rhegmatogenous retinal detachment.1 Although there are potential side effects and complications of any form of retinal detachment repair, the benefits of treatment out¬ weigh the risks in these symptomatic eyes.2"4 The treatment of a patient without symptoms found to have a retinal detachment on routine examination is less well defined. There are few published reports concern¬ ing asymptomatic rhegmatogenous retinal detachments. Jarrett,3 in his American Ophthalmological Society thesis, presented 16 cases of asymptomatic rhegmatogenous reti¬ nal detachment. Eight eyes were initially observed but even¬ tually underwent scierai buckling surgery. The reason for proceeding with surgery in most ofthese eyes was progres¬ sion of the detachment. The detachment progressed to in¬ volve the macula in only one of these eyes. The remaining eight eyes were observed for up to 10 years without progres¬ sion of the detachment. Benson et al6 published a retrospec¬ tive series of 66 cases of retinal detachment with demarca¬ tion lines. Twenty of the eyes were asymptomatic, and all were treated with a scierai bucklingprocedure. The reattach-


ment rate was 98%. In 51 of the 66 eyes, the retinal detach¬ ment the demarcation line. Their report

progressed beyond

indicated that most retinal detachments with demarcation lines should be treated with a scierai buckling procedure. The presence or absence of symptoms was not discussed as a factor in the decision to perform surgery. Tillery and Lucier7 described a series of 60 patients with retinal detachment caused by atrophie holes and lat¬ tice degeneration. Although some patients were asymp¬ tomatic, the exact numbers were not mentioned in the publication. All eyes were treated with a scierai buck¬ ling procedure, and 98% of retinas were successfully re¬ attached. Of 47 eyes in which follow-up visual acuity was available, 15% had worse visual acuity postoperatively. This increased to 31% of eyes with worse visual acuity postoperatively in a subgroup of their patients who had visual acuity of 20/40 or better preoperatively. To our knowledge, the only long-term data on natu¬ ral course pertaining to asymptomatic rhegmatogenous retinal detachments were published by Byer in 1989.8 He presented the follow-up data on 276 consecutive pa¬ tients with lattice degeneration. Asymptomatic subclini¬ cal retinal detachments were present in 10 of these pa¬ tients, who were followed up for 8 months to 23 years. Two patients showed slight progression but did not de¬ velop symptoms. One of these patients was treated with a segmentai scierai buckle. Based on these data, Byer did not recommend treatment for asymptomatic subclinical rhegmatogenous retinal detachments. The most important aspect of our patient population is the asymptomatic nature of the retinal detachments. Rheg¬ matogenous retinal detachments were diagnosed on a routine examination or in patients who presented with unrelated eye symptoms. In five patients, the asymptomatic retinal de¬ tachment was discovered when the patient presented with a symptomatic rhegmatogenous retinal detachment in the fellow eye. Two of these five patients were the two patients in the study who had progression to symptomatic retinal de¬ tachment. Although the numbers are too small to draw firm conclusions, this may indicate that asymptomatic retinal de¬ tachments in fellow eyes of patients witb symptomatic reti¬ nal detachment are at increased risk for progression. Treatment recommendations for other peripheral reti¬ nal lesions depends to a large extent on the presence or ab¬ sence of symptoms. This is particularly true of tractional retinal breaks. Byer9 followed up 46 phakic eyes with asymp¬ tomatic tractional tears for 1 to 18 years, and no detach¬ ments occurred during follow-up. The nonprogression of asymptomatic retinal tears to retinal detachment has also been demonstrated in aphakic eyes.10 These studies sup¬ port the contention that asymptomatic retinal tears need not be treated in most eyes. The absence of symptoms prob¬ ably indicates that the tear is not acute or not associated with ongoing tractional forces. This may also apply to asymptomatic rhegmatogenous retinal detachments. In a study of the natural course of asymptomatic reti¬ nal breaks, no retinal detachments occurred during acute posterior vitreous detachment.11 Since more than half of the eyes in our study did not have a posterior vitreous detachment, a concern might be that posterior vitreous detachment may cause progression of the retinal detach¬ ment. Further long-term follow-up of patients with asymp-

tomatic retinal detachment will help determine the sig¬ nificance of posterior vitreous detachment in these eyes. The mean age of our patients was 49 years. This is com¬ parable with the ages in previously published series of reti¬ nal detachments caused by atrophie holes in lattice degen¬ eration7 and retinal detachments with demarcation lines.6 Younger individuals have less vitreous liquefaction and a lower incidence of posterior vitreous detachment.12 Another subgroup of eyes that can present with chronic or slowly progressive retinal detachment includes those with retinal dialyses.13 Although no patients included in our study had retinal dialyses as the cause of the asymptomatic reti¬ nal detachment, we followed up a patient with an asymp¬ tomatic retinal detachment caused by a presumed posttraumatic dialysis after we compiled the data for this study. We elected to observe this eye, and the detachment re¬ mained unchanged at 10 months of follow-up. In the two patients treated for progressive retinal de¬ tachment, patient education enabled prompt presentation to the physician as soon as symptoms developed, prevent¬ ing foveal detachment. Both underwent successful scierai buckling procedures with a good visual outcome. Patient education is essential for patients with asymptomatic reti¬ nal detachments. Instruction on self-testing of the visual field is important in these patients. The potential for progression of the detachment as well as the side effects and complica¬ tions of retinal detachment repair should be reviewed with the patient so that he or she can participate in the manage¬ ment decision. Patients with more posteriorly located reti¬ nal detachments with objective evidence of visual field loss should be informed of the possibility that repair of the reti¬ nal detachment may improve the visual field defect. Based on this retrospective study, observation should be consid¬ ered a reasonable option in the treatment ofreliable patients with asymptomatic rhegmatogenous retinal detachment.

Accepted for publication March 17,1995. Reprint requests

pus, 2108 Medical 17604-3200 (Dr

to Lancaster

Offices Bldg,

General Health Cam¬ 310, Lancaster, PA

Suite

rod).

REFERENCES 1. American Academy of Ophthalmology Preferred Practice Patterns: Retinal Detachment. San Francisco, Calif: American Academy of Ophthalmology; 1990. 2. Wilkinson CP, Bradford RH Jr. Complication of draining subretinal fluid. Retina.

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Smiddy WE, Loupe D, Michels RG, Enger C, Glaser BM, deBustros S. Extraocular muscle imbalance after scleral buckling surgery. Ophthalmology. 1989:96:1485. 4. Chen JC, Robertson JE, Coonan P, et al. Results and complications of pneumatic retinopexy. Ophthalmology. 1988:95:601. 5. Jarrett WH. Retinal detachment. Trans Am Ophthalmol Soc. 1988;86:307-320. 6. Benson WE, Pornsawat N, Morse PH. Characteristics and prognosis of retinal detachments with demarcation line. Am J Ophthalmol. 1977;84:641-644. 7. Tillery WV, Lucier AC. Round atrophic holes in lattice degeneration. Trans Am Acad Ophthalmol Otolaryngol. 1976;81:509-518. 8. Byer NE. Long-term natural history of lattice degeneration of the retina. Ophthalmology. 1989;96:1396-1402. 9. Byer N. The natural history of asymptomatic retinal breaks. Ophthalmology. 3.

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10. Friedman Z, Neumann E. Posterior vitreous detachment after cataract extraction in non-myopic eyes and the resulting lesions. Br J Ophthalmol. 1975;59:451-454. 11. Byer NE. Rethinking prophylactic treatment of retinal detachment. In: Stirpe M, ed. Advances in Vitreoretinal Surgery. New York, NY: Ophthalmic Communications Society; 1992:399-411. 12. Foos RY, Wheeler NC. Vitroretinal juncture. Ophthalmology. 1982;89:1502-1512. 13. Hagler WS, North AW. Retinal dialyses and retinal detachment. Arch Ophthalmol. 1968;79:376-388.
