Acta Ophthalmologica 2014
Review Article Prophylactic treatment of retinal breaks – a systematic review Søren Blindbæk and Jakob Grauslund Department of Ophthalmology, Odense University Hospital, Odense, Denmark
ABSTRACT. Prophylactic treatment of retinal breaks has been examined in several studies and reviews, but so far, no studies have successfully applied a systematic approach. In the present systematic review, we examined the need of follow-up after posterior vitreous detachment (PVD) – diagnosed by slit-lamp biomicroscopy or Goldmann 3-mirror examination – with regard to retinal breaks as well as the indication of prophylactic treatment in asymptomatic and symptomatic breaks. A total of 2941 publications were identified with PubMed and Medline searches. Two manual search strategies were used for papers in English published before 2012. Four levels of screening identified 13 studies suitable for inclusion in this systematic review. No meta-analysis was conducted as no data suitable for statistical analysis were identified. In total, the initial examination after symptomatic PVD identified 85–95% of subsequent retinal breaks. Additional retinal breaks were only revealed at follow-up in patients where a full retinal examination was compromised at presentation by, for example, vitreous haemorrhage. Asymptomatic and symptomatic retinal breaks progressed to rhegmatogenous retinal detachment (RRD) in 0–13.8% and 35–47% of cases, respectively. The cumulated incidence of RRD despite prophylactic treatment was 2.1–8.8%. The findings in this review suggest that follow-up after symptomatic PVD is only necessary in cases of incomplete retinal examination at presentation. Prophylactic treatment of symptomatic retinal breaks must be considered, whereas no unequivocal conclusion could be reached with regard to prophylactic treatment of asymptomatic retinal breaks. Key words: posterior vitreous detachment – prophylaxis – retinal breaks – review – rhegmatogenous retinal detachment – treatment
Acta Ophthalmol. ª 2014 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
Introduction Rhegmatogenous retinal detachment (RRD) is a severe potentially vision threatening condition, caused by subretinal ﬂuid accumulating in the potential space between the neurosensory retina and the underlying retinal pigment epithelium. As derived from the name, rhegmatogenous retinal detachment is
preceded by a discontinuity or break in the retina. The incidence of retinal breaks or tears in the general population has been found in 2–9% of eyes examined in autopsy studies and clinical series. (Okun 1961; Halpern 1966; Byer 1967; Rutnin & Schepens 1967; Barishak & Stein 1972; Foos 1975). Several studies have tried to identify when prophylactic treatment is indicated as only a minor proportion of
retinal breaks will progress to retinal detachment. (Mitry et al. 2011) (Kramer & Benson 1977; Markham & Chignell 1977; Meyer-Schwickerath & Fried 1980; Kazahaya 1995; Wilkinson 1999, 2000, 2012; Carvounis & Holz 2006) A single attempt has been made to conduct a high-quality review which only included randomized controlled trials. (Wilkinson 2012) Unfortunately, no studies of this design were identiﬁed for eligibility, leaving this attempt of a systematic review inconclusive. The remaining reviews were all based only on observational studies of variable quality (evidence level 3 and 4), all without a systematic approach. Given the lack of high-quality research on this subject, the aim of this study was to provide the best available evidence on (i) the risk of retinal tears after posterior vitreous detachment (PVD) with regard to the need of follow-up, (ii) the risk of progression of non-treated asymptomatic and symptomatic retinal tears to RRD and (iii) the eﬀect of prophylactic treatment as prevention of RRD. From a clinical point of view, we wanted to examine whether prophylactic treatment is indicated in patients with asymptomatic and symptomatic retinal tears.
Methods This study was performed in accordance with the guidelines outlined by preferred reporting items for systematic reviews and meta-analyses (PRISMA). (Moher et al. 2009) The search strategy was set up to minimize the inﬂuence of heterogeneous
Acta Ophthalmologica 2014
populations on the analysis. No metaanalysis was conducted as none of the included studies presented data that were suitable for statistical calculation. A search was performed with search terms as follows in the PubMed and Medline databases: (retina[Title/Abstract] OR retinal [Title/Abstract]) AND (break[Title/ Abstract] OR breaks[Title/Abstract] OR tear[Title/Abstract] OR tears [Title/Abstract] OR hole[Title/ Abstract] OR holes[Title/Abstract]) AND (detachment OR detachments). This search yielded 2933 hits (Fig. 1). Two additional manual search strategies were used to identify additional studies. Firstly, references of the studies identiﬁed from the electronic search strategy were screened. Secondly, a speciﬁc search of authors with multiple publications on the subject of retinal tears and retinal detachment was performed. These eﬀorts yielded
2933 studies identified via PubMed/Medline
1290 studies identified for initial screening
170 abstracts retrieved
eight studies not identiﬁed by the initial search that fulﬁlled the criteria of eligibility in so far that full-text articles were retrieved. None of the studies identiﬁed in this manner was ﬁnally included in this review. In the selection process, the search was limited only to include studies published before 2012. Animal studies, letters, reviews, duplicates, comments and publications in languages other than English were excluded. Studies that were obviously not primarily related to retinal tears were discarded by screening the titles, that is, studies that described or compared surgical procedures for retinal detachment surgery, studies on ocular trauma other than cataract surgery and studies on diabetic retinopathy, age-related macular degeneration, coloboma or other primary ocular or systemic diseases known to predispose to vitreoretinal disease other than myopia. Also studies
8 studies identified via manual search strategies
o o o o o o o o
Case reports: 601 Comments: 22 Letters: 56 Reviews: 153 Animal studies: 113 Not English: 689 After 01/01/2012: 14 Duplicates removed: 3
1120 studies excluded: o Other primary disease (ocular or systemic) o Comparison or descriptions of methods for detachment surgery o Trauma to the eye other than cataract surgery o Macular hole o Giant retinal tear o 101 studies not relevant o Two studies not identified
67 full-text articles retrieved
13 articles suitable for inclusion
o < 20 eyes: 2 o No data published: 8 o Multiple publications on same cohort: 2 o Data not consecutive: 4 o Estimation of data: 1 o Incomparable data: 37
Fig. 1. Flowchart demonstrating the selection process.
on macular holes and giant retinal tears were excluded as these conditions were considered mandatory vision threatening and therefore required treatment. For the remaining 170 studies, abstracts were retrieved. Of these, non-interventional studies on symptoms of vitreoretinal disease, methods for identiﬁcation of retinal tears and studies otherwise not of relevance (i.e. not related to the aim of this review) were excluded. Of the remaining 69 studies, 67 full-text articles were reviewed. Two studies could not be identiﬁed as full-text articles. Of the full-text articles, studies with no published data and studies based on estimated data created upon theoretical considerations were excluded. When studies that used the same cohorts of eyes/patients were identiﬁed, the study with the largest number of eyes/ patients was selected. To minimize the impact of selection bias, only studies that included consecutive patients were included as well as studies with cohorts 6 months
6 month – 6 years
6 month – 9 years
1974 1982 1960
48 177 88
RCP LPC/RCP RCP
– 13 (7.3) –
LPC, laser photocoagulation, RCP, retinocryopexy.
2 (4.2) 8 (4.5) 4 (4.6)
6 month – 10 years >6 month >3 month
Acta Ophthalmologica 2014
regard to risk factors. For this reason, the composition of eyes with high-risk asymptomatic breaks, symptomatic breaks, breaks in fellow eyes to detachment and varying degrees of myopia diﬀered markedly in the populations of the individual studies. Subtypes of retinal breaks
The occurrence of new retinal tears in eyes in which prophylactic treatment was initially considered successful, query the general perception of RRD as a condition that originates from tractional tears as a consequence of PVD. As mentioned earlier, PVD was found in 87.6% of all RRDs, leaving 12.4% of RRDs unrelated to PVD. In a large prospective surveillance study, with a total of 1202 included cases of RRD during a 2-year period, round hole RRD comprised 40% of the RRDs not related to PVD. In all RRDs related to PVD, only tears considered to be tractional were identiﬁed (98.5% horseshoe tears and 1.5% giant retinal tears). (Mitry et al. 2011). The presence or absence of PVD was not taken into account in any of the studies that evaluated the eﬀect of prophylactic treatment. The fact that approximately 12% of RRDs were not preceded by PVD suggests that other pathology than PVD can be present and suﬃcient treatment probably cannot be expected to be achieved if only considered as so. It is reasonable to assume that higher rates of success in prophylactic treatment can be achieved if only breaks considered to be tractional are evaluated, at least in terms of the incidence of new retinal breaks. However, the studies identiﬁed eyes of very heterogeneous composition with various risk factors for retinal detachment, and therefore, no substantial evidence supports this assumption. Also the possibility that not all retinal breaks were identiﬁed at the initial examination may account for an unknown proportion of the breaks stated as ‘new’. Diagnostic imaging has become a signiﬁcant supplement of traditional slit-lamp examination although its clinical value is still to be prospectively examined in detail. Future studies to evaluate methods of wide-ﬁeld imaging are anticipated within the years to come. (Mackenzie et al. 2007).
Discussion This review is the ﬁrst to apply a stringent systematic approach. We aimed to provide a clinically applicable examination of the present literature on PVD with regard to the need of follow-up and prophylactic treatment of retinal breaks. The validity of our results is emphasized by a thoroughly documented method and selection process. Data presented in this review suggest that follow-up after symptomatic PVD is only indicated in eyes in which a full retinal examination cannot be performed at presentation. Furthermore, this study found an incidence of RRD of 0–13.8% and 35–47% in eyes with asymptomatic and symptomatic retinal breaks, respectively, compared with a cumulated incidence of subsequent retinal detachment after prophylactic treatment of 2.1–8.8%. Therefore, prophylactic treatment must be considered in symptomatic retinal breaks. On the other hand, no deﬁnite conclusion could be reached in regard to prophylactic treatment of asymptomatic retinal breaks. This systematic review was considerably limited as only observational studies and case series were identiﬁed. Therefore, meta-analysis was not possible. Especially, the lack of any randomized controlled trials was problematic when the eﬀect of prophylactic treatment was evaluated. Due to ethical considerations with reference to the potential severity of RRD, several challenges limit the attempt to conduct randomized controlled trials. Apart from the studies on PVD, no ﬁxed time frame of follow-up had been deﬁned in advance in the included studies. This complicated the calculation of a cumulated incidence of events as this would usually require an exact time period. In this review, only an approximation of the cumulated incidence could therefore be reported, estimated as the number of new events during the minimum time of follow-up reported. Other limitations would be the heterogeneity of the populations in the studies included, the ageing of most of the studies and the numerous risk factors represented in various proportions in the diﬀerent studies which might have caused some confounding when studies were compared.
More well-designed studies are needed to shed further light on this subject – preferably randomized controlled trials or as minimum observational studies designed to control confounding variables.
References Barishak YR & Stein R (1972): Retinal breaks without retinal detachment in autopsy eyes. Acta Ophthalmol (Copenh) 50: 147–159. Boldrey EE (1983): Risk of retinal tears in patients with vitreous ﬂoaters. Am J Ophthalmol 96: 783–787. Byer NE (1967): Clinical study of retinal breaks. Trans Am Acad Ophthalmol Otolaryngol 71: 461–473. Byer NE (1982): The natural history of asymptomatic retinal breaks. Ophthalmology 89: 1033–1039. Byer NE (1994): Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment. Ophthalmology 101: 1503– 1513; discussion 1513–1504 Carvounis PE & Holz ER (2006): Management of retinal breaks and conditions predisposing to retinal detachment. Compr Ophthalmol Update 7: 13–22. Coﬀee RE, Westfall AC, Davis GH, Mieler WF & Holz ER (2007): Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis. Am J Ophthalmol 144: 409– 413. Colyear BH Jr & Pischel DK (1960): Preventive treatment of retinal detachment by means of light coagulation. Trans Pac Coast Otoophthalmol Soc Annu Meet 41: 193– 217. Combs JL & Welch RB (1982): Retinal breaks without detachment: natural history, management and long term follow-up. Trans Am Ophthalmol Soc 80: 64–97. Davis MD (1974): Natural history of retinal breaks without detachment. Arch Ophthalmol 92: 183–194. Dayan MR, Jayamanne DG, Andrews RM & Griﬃths PG (1996): Flashes and ﬂoaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment? Eye (Lond) 10 (Pt 4): 456– 458. Fan DS, Lam DS & Li KK (1999): Retinal complications after cataract extraction in patients with high myopia. Ophthalmology 106: 688–691; discussion 691–682. Foos RY (1975): Tears of the peripheral retina; pathogenesis, incidence and classiﬁcation in autopsy eyes. Mod Probl Ophthalmol 15: 68–81. Greven CM (2009): Retinal Breaks. In: Yanoﬀ M, Duker JS (eds). Ophthalmology, 3rd edn. Edinburgh: Mosby Elsevier 716–719.
Acta Ophthalmologica 2014
Halpern JI (1966): Routine screening of the retinal periphery. Am J Ophthalmol 62: 99– 102. Hikichi T & Trempe CL (1994): Relationship between ﬂoaters, light ﬂashes, or both, and complications of posterior vitreous detachment. Am J Ophthalmol 117: 593–598. Javitt JC, Vitale S, Canner J, Krakauer H, McBean AM & Sommer A (1991): National outcomes of cataract extraction. I. Retinal detachment after inpatient surgery. Ophthalmology 98: 895–902. Kanski JJ (1999). Clinical Ophthalmology, London: Reed Educational and Professional Publishing Ltd. Kanski JJ & Daniel R (1975): Prophylaxis of retinal detachment. Am J Ophthalmol 79: 197–205. Kazahaya M (1995): Prophylaxis of retinal detachment. Semin Ophthalmol 10: 79–86. Kramer SG & Benson WE (1977): Prophylactic therapy of retinal breaks. Surv Ophthalmol 22: 41–47. Kuhn F & Aylward B (2014): Rhegmatogenous retinal detachment: a reappraisal of its pathophysiology and treatment. Ophthalmic Res 51: 15–31. Mackenzie PJ, Russell M, Ma PE, Isbister CM & Maberley DA (2007): Sensitivity and speciﬁcity of the optos optomap for detecting peripheral retinal lesions. Retina 27: 1119–1124. Markham RH & Chignell AH (1977): Current status of prophylaxis of retinal detachment. Trans Ophthalmol Soc UK 97: 482–484. Meyer-Schwickerath G & Fried M (1980): Prophylaxis of retinal detachment. Trans Ophthalmol Soc UK 100 (Pt 1): 56–65. Mitry D, Singh J, Yorston D, Siddiqui MA, Wright A, Fleck BW, Campbell H & Charteris DG (2011): The predisposing pathology
and clinical characteristics in the Scottish retinal detachment study. Ophthalmology 118: 1429–1434. Mitry DJ, Singh J, Yorston D et al. (2012): The fellow eye in retinal detachment: ﬁndings from the Scottish Retinal Detachment Study. Br J Ophthalmol 96: 110–113. Moher D, Liberati A, Tetzlaﬀ J & Altman DG (2009): Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339: b2535. Okun E (1961): Gross and microscopic pathology in autopsy eyes. III. Retinal breaks without detachment. Am J Ophthalmol 51: 369–391. Pollak A & Oliver M (1981): Argon laser photocoagulation of symptomatic ﬂap tears and retinal breaks of fellow eyes. Br J Ophthalmol 65: 469–472. Richardson PS, Benson MT & Kirkby GR (1999): The posterior vitreous detachment clinic: do new retinal breaks develop in the six weeks following an isolated symptomatic posterior vitreous detachment? Eye (Lond) 13 (Pt 2): 237–240. Robertson DM & Norton EW (1973): Longterm follow-up of treated retinal breaks. Am J Ophthalmol 75: 395–404. Romem M & Singer L (1978): Long-term follow-up of photocoagulated retinal breaks. Br J Ophthalmol 62: 240–242. Rutnin U & Schepens CL (1967): Fundus appearance in normal eyes. IV. Retinal breaks and other ﬁndings. Am J Ophthalmol 64: 1063–1078. Sebag J & Balazs EA (1989): Morphology and ultrastructure of human vitreous ﬁbers. Invest Ophthalmol Vis Sci 30: 1867–1871. Shea M, Davis MD & Kamel I (1974): Retinal breaks without detachment, treated and
untreated. Mod Probl Ophthalmol 12: 97– 102. Smiddy WE, Flynn HW Jr, Nicholson DH, Clarkson JG, Gass JD, Olsen KR & Feuer W (1991): Results and complications in treated retinal breaks. Am J Ophthalmol 112: 623–631. Wilkinson CP (1999): Evidence-based medicine regarding the prevention of retinal detachment. Trans Am Ophthalmol Soc 97: 397–404; discussion 404–396. Wilkinson CP (2000): Evidence-based analysis of prophylactic treatment of asymptomatic retinal breaks and lattice degeneration. Ophthalmology 107: 12–15; discussion 15–18. Wilkinson CP (2012): Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment. Cochrane Database Syst Rev 3: CD003170. Williams KM, Watt L & Williamson TH (2011): Acute symptomatic posterior vitreous detachment and delayed retinal breaks. Acta Ophthalmol 89: e100–e101.
Received on July 3rd, 2013. Accepted on April 20th, 2014. Correspondence: Jakob Grauslund, Department of Ophthalmology Odense University Hospital Sdr. Boulevard 29 DK-5000 Odense C Denmark Tel: +45 2127 1877 Fax: +45 6612 6387 Email: [email protected]
The authors have no conﬂicts of interest.