06 Nov Preventing Giant Retinal Tears
Giant retinal tears (GRT) are the worst type of retinal detachment. These types of retinal detachment have higher surgical complications, are more difficult to fix and often lead to legal blindness or worse.
Rhegmatogenous retinal detachments are the more common types of retinal detachments. A retinal tear or retinal hole may lead to a retinal detachment. In contrast to a rhegmatogenous retinal detachment, a giant retinal tear is caused by a large circumferential tear of at least 3 clock hours, or 25% , of the peripheral retina.
While all retinal detachments are potentially blinding, the more common rhegmatogenous retinal detachment has a better visual prognosis.
Due to the poor visual outcomes, it is common practice to consider treatment to the fellow eye (the eye not suffering the GRT) to prevent a giant retinal tear from forming.
In the video, this patient is young and very, very near-sighted. This patient developed a giant retinal tear in the left eye about 1 year ago. Although the sight was completely restored, I was anxious to treat the right eye, to prevent a GRT from occurring in that eye.
The more common approach to prophylaxis of a GRT is to perform laser treatment to the peripheral retina. The same treatment used in patients with proliferative diabetic retinopathy can be applied to the peripheral retina. The idea is to create laser burns to the area of the retina likely to tear…the most anterior portions of the retina.
Laser treatment is usually performed in the office setting, with or without local anesthesia (I prefer using anesthesia), and can be performed in one visit.
As you watch the end of the video. I am treating the peripheral and most anterior retina with laser treatment. I am principally interested in “tacking down” or reinforcing the area of the retina most prone to tearing.
At the basis of any retinal tear, giant or otherwise, is the vitreous. The vitreous is very adherent to the peripheral, or anterior, retina. The vitreous pulls on the retina causing the tears.
Removing the vitreous, therefore, removes the causative agent to the whole process. In other words, by removing the vitreous, I am also removing the principle cause of the retina detachment.
Vitrectomy is a common procedure for a retinal specialist. Vitrectomy is commonly performed for retinal detachments, epiretinal membranes, macular holes, floaters, blood removal, etc.
In the video, the vitreous is seen as opaque fluffy material which “jiggles” as I operate. I can usually see most of the vitreous making it easy to remove.
What Does this Mean?
In theory, vitrectomy and laser prevents a retinal detachment from a giant retinal tear in two ways; removal of the agent causing the tear and reinforcing the retina to withstand any pulling forces by the vitreous. The vitrectomy has few complications, but blinding infection is possible.
On the other hand, I feel the benefit of preventing a GRT merits the risk of infection…less than 1:10,000.