Retinal breaks without detachment: natural history, management and long term follow-up

A group of patients with retinal breaks without detachment were analyzed. They were divided into a treatment and a nontreatment group. The treatment group consisted of cases that the authors felt to be at high risk for the development of retinal detachment. Most of these were cases of horseshoe tears following the onset of an acute posterior vitreous detachment. Although a number of modalities were used in the treatment, a transconjunctival cryotherapy approach with topical anesthetic drops is currently used and was the most frequently employed. It is of note that while no case in this series developed a detachment because of inadequate treatment of the original tear a certain number did develop new tears and detachments. This would speak for a frequent follow-up, especially within the first three months following treatment, to anticipate such an occurrence. In the untreated group there were essentially two types of patients. One was the asymptomatic patient in which a retinal tear was found on routine examination and the other was the symptomatic patient with a round hole with pulled out operculum. New tears and or detachments also occurred in the asymptomatic group (4 of 72 eyes) but none of the round holes with pulled out opercula detached. Complications of treatment were related to the anesthesia and included vasovagal reactions and retrobulbar hemorrhage. One case seen in consultation had evidence of scleral perforation from a bridle suture and illustrates the inherent danger in any ophthalmic ocular procedure. The question of macular pucker (pre-retinal fibrosis) as a high risk of treatment is not shown by this study and in fact was more common in the untreated group than the treated group; however the vision of patients with macular pucker in the treated group was generally less than that of those untreated. Recurrent vitreous hemorrhage from bridging or avulsed vessels represented a significant problem following treatment and led to the only case of total visual loss in this study. The prophylactic treatment of acute horseshoe tears with continuing vitreous traction significantly reduces the incidence of subsequent retinal detachment. Whatever method of treatment is chosen by the surgeon, he must follow the principles laid down many years ago by Jules Gonin and completely close the tear. However, it is important to recognize that a new tear or detachment may occur in some cases and seems related to the continuing evolution of the posterior vitreous detachment or residual vitreo-retinal adherence rather than a cause of the treatment itself.