Patient Care 
Lesions in the Periphery: Part 2 or 2

How to Manage Them

Once you identify a retinal lesion, appropriate management depends on your ability to evaluate th e risk of detachment. 
By REX BALLINGER, O.D., Baltimore

Identifying peripheral retinal lesions and differentiating retinal breaks and detachments will enable you to determine the right course of patient care. So will your ability to distinguish a lesion that may progress to retinal detachment from one that’s benign. The first installment of this two-part series discussed how to identify lesions. This month, I’ll explain how to manage them—indeed, if you should manage them at all. 

When to Treat

When determining whether you should refer a patient for treatment, you must weigh the risk of that against the benefits of preventing a retinal detachment. The AOA offers guidelines on the management of peripheral retinal lesions and retinal breaks.1,2

Treatment is indicated for symptomatic retinal breaks, fresh full thickness tears with traction, large multiple breaks, and breaks associated with vitreous hemorrhage and trauma. Flap tears are often indicated for treatment. Operculated tears may require treatment, but that depends on the nature of the break—its symptoms, risk factors, subretinal fluid or traction on the adjacent attached retinal tissue. 

Treatment is not indicated for atrophic holes that do not have subretinal fluid. Asymptomatic tears, especially those that are intrabasilar, carry a lower risk of retinal detachment. Free-floating operculated holes without traction or subretinal fluid carry a low risk. Atrophic holes in lattice degeneration also have a low risk of retinal detachment in older patients. There is no indication for treatment of atrophic holes in lattice without subretinal fluid in older patients who do not have significant risk factors.

Aphakic patients carry a higher risk of retinal detachment than pseudophakic individuals. Some risk comes with cataract extraction, depending on the volume of lens material removed. The vitreous is likely to move forward, causing increased traction on the retina. The risk is smaller if the capsule is intact postoperatively. The risk also increases after YAG capsulotomy.

Retinal Tufts

Most retinal tufts will not progress to retinal breaks. Management of these lesions is rather straightforward. Your role is to document and monitor them, as well as educate the patient about the signs and symptoms of retinal detachment so he or she knows when to come in. As long as there are no other risk factors, you can review the lesion annually in young patients. If the patient is older with a posterior vitreous detachment, you need to monitor the lesions more closely for breaks before a retinal detachment occurs.

Here’s how to manage these specific types of retinal tufts:

  • Non-cystic tuft. This is a very small lesion commonly found between the equator and ora serrata. A non-cystic tuft is essentially benign. Manage by documenting its location and monitoring it. Occasionally the tips of the tuft may break free of the retina later in life, producing a vitreous floater. However, these lesions are unlikely to be associated with a retinal break and carry a low risk for retinal detachment.
  • Cystic retinal tuft. These lesions may result in partial or full-thickness retinal breaks. Such breaks often occur with a posterior vitreous detachment, but they may also occur with vitreal traction in the absence of posterior vitreous detachment. If there’s no relief of the traction, a progressive retinal tear and detachment may ensue. 

  • Again, management of cystic retinal tufts consists of documenting and monitoring them. Should traction or a posterior vitreous detachment occur, observe the lesion with scleral depression to discern if there is a full-thickness break. If the patient is symptomatic, laser photocoagulation is indicated for prophylaxis. If there is traction on the lesion with a full-thickness break and sub-retinal fluid, refer for consultation for treatment, either with laser, pneumatic retinopexy or a scleral buckle procedure. This is especially true in patients with risk factors such as myopia or a family history of retinal detachments. 
    The size and nature of the retinal break dictates the type of treatment. Laser retinopexy is often indicated for small breaks. Large breaks may require pneumatic retinopexy, cryotherapy and/or scleral buckling. Full retinal detachments, complicated retinal detachments and those with multiple breaks often require scleral buckling. (An in-depth discussion of these procedures is beyond the scope of this article.) If you refer a patient and he receives laser retinopexy, the procedure should encompass the entire lesion.
  • Zonular traction tuft. This type of tuft develops within the vitreous base. The base of the lesion is typically comprised of retinal and glial tissue that extends up off the retina, along the pars plana area and to the ciliary processes. The lesion may result in a retinal break due to trophic changes or traction. If a break occurs, it may form a partial or full-thickness retinal tear at the lesion’s base. The risk of detachment is less than it would be with cystic retinal tufts—that is, if the base of the zonular traction tuft is within the vitreous base. In some cases, treatment may prevent further complications. 

Retinoschisis

The challenge in managing retinal detachment vs. retinoschisis is to first determine whether retino-schisis is indeed cause for the lesion, or if it’s due to an old atrophic retinal detachment. As we reviewed last month, several features help distinguish the two. 

Inferior retinal detachments may appear to have the same configuration as a retinoschisis, so scleral depression is your key to distinguishing the two. On depression, the schisis cavity maintains its configuration, while a retinal detachment will often appear to deflate. Further, outer retinal layers of schisis often become whitish on scleral depression. 

Retinal pigment epithelial changes don’t usually occur in retinoschisis, though you may observe them infrequently. These changes can occur within the lesions or along the edge. RPE changes often occur with atrophic retinal detachments because the RPE depends on the retinal tissue to maintain function. When the retina separates from the RPE, the latter becomes disturbed and eventually atrophies.

Also, retinoschisis is rigid, while retinal detachments often undulate with eye movement. However, long-standing detachments may not move as readily as fresh ones. If the lesion is of significant size and posterior to the equator, it may manifest on a visual field exam.

Again, management of retino-schisis is straightforward: Most cases do not require treatment. In rare cases, treatment may be indicated when a retinoschisis develops into a progressive retinal detachment. Lesions that do not usually require treatment are ones posterior to the equator, that progress toward the macula, have inner holes or exist with a retinal detachment in the fellow eye. The exception is when any of these show a progressive retinal detachment.

Lattice Degeneration

In patients 40 and older, retinal breaks may occur at the posterior edge of lattice degeneration due to vitreoretinal traction, perhaps at the time of posterior vitreous detachment. The tears may be small or large, single or multiple. Retinal detachment may occur with the breaks, or they may occur from atrophic holes within or near lattice lesions. Carefully examine areas adjacent to the lattice lesion for retinal breaks. 

Retinal detachment with lattice usually occurs when the vitreous fluid leaks into the subretinal space. The risk of detachment from atrophic holes is higher in patients under age 30 than in older patients. If there is significant subretinal fluid (usually greater than 1 disk area from the hole), evaluate the patient for treatment.

Other Retinal Lesions 

How should you manage retinal lesions overall? In order to assess the risk of retinal breaks and retinal detachment, you must consider several factors, in this order: 
  • Is the patient at risk? Does the patient have a posterior vitreous detachment, myopia over -3.00-5.00D or a family history of retinal detachment? Has the patient had any intraocular surgery such as cataract extraction? Has the patient ever had any prior history of intra-ocular inflammation, trauma or infections? Is the patient diabetic with retinopathy? Does the patient have any systemic disease that may lead to increased risk for retinal detachment?
  • Is there a retinal break? Scleral depression is the best method to determine if the retinal tissues and concomitant subretinal fluid have separated. 
  • Is the patient symptomatic? If so, the patient is at greater risk of developing a retinal detachment. 
  • Is there traction on the retina? Persistent traction raises the risk of detachment. Again, you can appreciate this using scleral depression. 
You should also evaluate the risk of clinically significant detachments vs. subclinical detachments—those that occur when fluid extends more than 1 disk diameter beyond the edge of the break but not more than 2 disk diameter posterior to the equator. How much is too much? Any fluid extending more than 1 disk area from the lesion’s edge raises the risk for detachment. A positive answer to any of these questions would indicate treatment.

As optometry becomes ever more involved in diagnosing and managing disorders in the entire eye, our ability to identify retinal lesions and determine the risk for detachment becomes crucial for us to provide lifetime care to our patients. Often, these lesions require only observation and documentation. Knowledgeable and vigilant optometric care will help ensure that these patients get the appropriate care, and help preserve their functional vision.
 

Dr. Ballinger is an attending optometric physician at the Veteran’s Affairs Medical Center in Baltimore.
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May 15, 2001